rethinking the use of the word ‘simple’ in global health & development (III)

suvojit made some great points that turned into (what i think is) an interesting conversation. check it & think about what ‘best buys‘ in development really mean.

plus, generally check out suvo! we’re all better off since he decided to stop and blog every now and then.

traveling pants (absolutely nothing to do with a sisterhood)

From a letter home from India in 2008:

The topic of this section is pants.  It requires a small introduction.  For the most part, I wear my own pants and have purchased some of the long tops with slits up the sides (kurta) that most of the girls with whom I work (unmarried, so generally pre-sari) wear.  Most of the girls buy entire outfits, with coordinating pants, top and shawl (salwar kameez).  I do not do this.  First, I think the shawls can a pain to wear all the time.  Second, I am not used to ‘outfits.’  I like trying different pants and tops together.  The outfit concept seemed quite stifling.  Third, I despise the pants.  They come in two basic varieties, neither of which stretches or moves with you the way pants do at home.  The first are mildly balloony at the top and then tight all the way down – basically, jodhpurs (churidar).  These don’t do it for me.  The currently fashionable pants are huge, with a zillion pleats at the top and then ballooning out and coming in tight at the ankle.  To be sure, they look quite elegant on some woman.  However, those will always and forever mean only one thing to me: they are MC Hammer pants, and I cannot wear them.

Anyway, I had been trying to do my own laundry.  Then, I accidentally dyed two pieces of clothing the wrong color.  I guess I wasn’t thinking that the dyes here were quite so strong — or just wasn’t thinking in general.  Frankly, it is probably the best tie-dye work I have ever done, except that since it was unplanned, it is only dyed in some places.  Besides this, I just felt that my clothes were never really clean.  So, I have in and took them to a laundry/dry cleaners.  As far as I can tell, laundromats are not are not an option here.  And, I had been putting off using the laundry for another reason.  They keep your clothes for a week, so I had to go on a shopping trip so I had enough clothes to last for the week while the other half were being washed.  Once that was done, off the first round of clothes went.  About an hour after I left the clothes, I got a panicked call from the man at the laundry.  ‘The green pants you left?  The bottom hem is gone.  I mean, it is entirely gone.’

‘Oh dear,’ I replied.  ‘Well, please wash them anyway.’  That’s what I said.  What I was thinking was: Of course it is gone.  I bought them that way.  They are created to exist without the bottom hem.  It is supposed to be cool.  I had a similar conversation with Aberna about my J Crew-orange pants that, when they were brand new, looked like they had been faded in the sun.  ‘Oooh, these pants are very faded, aren’t they?  That is not good.’  I am never sure in these conversations when to do a bit of cultural teaching and explain precisely how much I paid for the pants to look just they way they do.  This is a similar conversation as to when we talk about the fabric of my clothing.  Aberna will touch my clothes and say, ‘Oooh, do you think this fabric is good?’  What she is asking is, ‘This is not 100% cotton, is it?’  Again, there is no good way to explain that being 100% cotton is not necessarily a status symbol in the US or a weather-dictated necessity and that the only reason I check the cotton content of clothes when I am purchasing them is to see if they will shrink in the wash.

Anyway, back to distressed and faded clothes.  There was an article in Vogue not so long ago about a similar topic.  It discussed the rise of jeans as an appropriate dress-up outfit and how it worked because people knew that you could afford to wear something fancier or nicer, but you had chosen not to do so.  Moreover, I remember John telling me about some similar confusions with antique shopping in China – ‘why would you want to buy something old?’

The lesson applies here as well: the distressed, the vintage and so forth only works when it is clearly an option, not when for most people it is a necessity.  That is, it does not work here.

a collection of a few possible relevant articles (II): beyond sachs to karaoke and stuff

The discussion on the Bank President seems to have moved to a slightly more productive place now that the nominations are (nearly) out. That is, to humility, insider-ness, and karaoke.

The remaining uber-challenges of development—finding new ways to encourage private sector growth, delivering services in the world’s toughest places, creating incentives for better governance—are all objectives that will require creativity and learning-by-failing. This means finding new ways to encourage innovation and experimentation by staff and clients.

The field still doesn’t understand the development process very well and we certainly can’t predict the impact of various interventions in complex social, political, and economic systems. We need to try, test, tweak, and then try some more.

The head of the World Bank doesn’t need to be the smartest person in the room or the one with a ready-made Best Plan Ever… The candidate should be someone with a model in mind that enables risk-taking and iterative approaches. If the World Bank is going to help find solutions to the lingering problems of global poverty and underdevelopment, its next President must be a person that comes to the job with a willingness to experiment and a heavy dose of, dare I say it, humility.

Rather than listening to the Washington Consensus, many developing countries took matters into their own hands at the turn of the century. Since then the developing world has grown faster than the rich, reduced poverty significantly and avoided the worst of the financial crisis that originated in the US. It would be ironic for the US to dictate the appointment at the World Bank in such an environment.

The World Bank is a full-service development institutions that provides loans and grants and development advice to promote development, which is the transformation of countries towards prosperous economies that support broad based improvements in material well-being, democratic polities that respect citizen rights and respond to citizen demands, and capable administrations that allow governments to carry out their core functions—law and order, education, macro-economic management, health, infrastructure, regulation, security.

Therefore an ideal candidate should have:

  • some experience in government and the process of policy-making (as the World Bank’s clients are all governments),
  • some acquaintance with economic policy and policy making—including the tough choices like allocation of resources across uses,
  • some knowledge of finance (it is, after all, a bank that makes income from lending money),
  • some management experience in a multilateral organization,
  • some exposure to the breadth of development issues.

OK, building from this last link — I have held a lot of different views about Jim Kim over the past many years of my schooling and involvement in public health but there are still some reasons why I think he could be good for the Bank. Among them, I appreciate his willingness to not just critique global agencies (WHO, Bank) and advocate for change but to accept positions within them and try to make a change.

However, suggesting that because he is a doctor he understands RCTs and is in support of evaluation is a serious over-reach. In fact, willingness to be evaluated and humility about their model is one of the easiest and most important critiques to be made of Partners in Health and, by perhaps-not-totally-fair implication, Jim Kim (PIH is beginning to try to rectify this – but nevertheless). Jim may have been more open and honest about his time at the WHO and 3×5 efforts, though one hopes we actually can do more than apologize and point out that the odds were against us.

A lot of ink and ego-juice has been spilled about whether the Bank’s past efforts have done more harm than good. Kim clearly leans toward one end of this argument. For policies as large-scale and not-done-in-a-vacuum as the Bank’s, either side will always be hard to prove – or even to consider objectively. However, I think most people can agree that the Bank’s efforts have not always done all the good they were expected to do, even if everyone had been totally committed to honestly appraising them. Which they have not.

In light of this, the list of qualities needed by the next President presents quite a tall order — an awesome manager that commands credibility and trust while also fostering creativity, risk-taking, learning-by-failure, humility — and remaining un-committed to any one ideology, economic or otherwise. To say, “we are going to try this is and we are not really sure if it is going to work,” is hard for anyone – from a mechanic, to hair stylist, to a doctor, to someone proposing to ‘tinker’ with a country’s economic, political, health, and other systems – such as those systems are in place and functioning. But, that is what we are up against. The randomista movement may be an expression of us not “understand[ing] the development process very well” but it still doesn’t fully help us overcome the challenge of “predict[ing] the impact of various interventions in complex social, political, and economic systems” – and eventually we do need to scale-up and that will always be hard to perfectly plan and evaluate (although, could Gary King at least get a small shout-out on this?). That said, a commitment to trying to monitor and evaluate it and a willingness to admit when things aren’t working, and investigating why they are not, is crucial. I think these qualities are something that we need to hear about all the candidates.

And, given the tallness of the order, maybe karaoke skills are really the best we can hope for. It is not the only time Jim Kim has overcome a challenge through karaoke – and I can think of a few countries to whom we probably owe a “Say Anything” moment. So, more on that about the candidates, too, please.

a collection of a few possibly relevant articles (I)

“The tone the president sets matters for the great machinery underneath,” she explains. “They determine in what direction it will grind along, and if it will do so in a way that makes sense. Will there be openness to a new direction and a readiness to admit problems and failures? All that is set at the level of the president.” for considering non-economists!

There needs to be a better disciplinary balance throughout the Bank—in research and operations. The policy environment needed to incentivise “growth that we want rather than the growth we get”, for example, is not going to be achieved by an exclusive reliance on economists. We need to understand how the rules of the growth game are set and modified if we want growth that better reduces poverty, growth that includes those on the margins of society, growth that better avoids environmental externalities and growth that disincentivises corruption. These rules of the game are rooted in norms, culture, history and many “noneconomic” (i.e. human) behaviours and are best understood and evolved by coalitions of disciplines working together.

To get big things done, the bank needs not just decent ideas from smart economists, but buy-in and cooperation from a diverse array of states. That’s a diplomatic job and a political job, and it’s exactly why the gig rightly belongs to someone with political experience on the international arena. Someone not like Jeffrey Sachs.

a new one (19 March) that is confused as I am about what the president of the Bank actually does – but weighs in on many possible angles:

To my mind the answer to the question whether Jeffrey Sachs would be a good head of the World Bank depends, at least in part, on what exactly the core functions of the head of the World Bank are. What do we really need them to be good at?… If it’s management, I’m unsure… If it’s ideas, I think he’d be alright… If it’s diplomacy, as Felix Salmon suggests it is, then maybe Sachs would be too bombastic. But I’m not so sure… Ultimately, the thing that counts against Sachs the most in my book is that he seems far too certain. And, it’s been a long time, I think, since he’s really – in an academic sense – engaged with evidence… My dream aid agency would be one that was openly plagued by doubt – one which wasn’t sure of itself but which let research lead policy (not the other way round as the World Bank was wont to do in the past). And which spent a lot of time and money on evaluations. And which openly discussed and debated it’s failures. For all its past problems the World Bank has seemed in recent years to be shambling in this direction. Which is great – and I fear Sachs would stifle this.

What’s needed at the World Bank is someone who knows development, but who isn’t deeply invested in their own normative ideas of what must be done. Running the Bank involves a delicate dance with extremely important and powerful shareholders who can effectively shut you down at any time… The World Bank is owned and run by sovereign governments, who will talk until they’re blue in the face about how they’re working for the world’s poorest, but who ultimately are not going to sign on to anything which they don’t perceive as being in their own best interest.

The project’s evaluation protocol states, “Issues of feasibility, political buy-in, community ownership and ethics also featured prominently in village selection.” This selection bias alone might have caused incomes at the treated sites to be higher, many years into the project, than incomes at the untreated sites—even if the project itself hadn’t caused that difference. Instead, incomes today are typically the same in the two groups.

There are valid reasons to debate which methodology is best for evaluating the impact of the MVP, and serious discussion of the components that should factor into this decision seem worthwhile. But fallacious statements such as those made in this post by Sachs and Singh do nothing to further the debate nor to encourage others considering large-scale interventions to seriously invest in rigorous impact evaluation.
One must also question what donors like the Soros Foundation and the UN relied on in terms of evidence when deciding to fund this second phase of the MVP project. Either donors are happy to fund such a program based on factors other than empirical evidence, or arguments like those above are misleading decision-making.

The goal of the MVP is to effect long-term change, building “a solid foundation for sustainable growth.”  So whether or not the project is effective can only be assessed in the long term.  That means that scaling up the project before any long-term evaluation would be scaling up an intervention of unknown effectiveness.

But without any such evaluation, the MVP has already called for “the model’s expansion throughout Africa” to affect millions of people. Researchers at the Overseas Development Institute already advocate for African governments to make “MVP-type investments” a “key component” of their national development strategies.  It would be irresponsible to vastly expand an intervention that is not known to accomplish its own stated, long-term goals.

I never picked the phrase “shock therapy,” and I have to say don’t much like it. It was something that was overlaid by journalism and public discussion. It sounds a lot more painful in a way than what it is.,hDe3IFe676E

This pessimistic note is confirmed in a vignette about Jeffrey Sachs, the former economic shock-therapy man who re-invented himself as the intellectual avatar of the Millennium Development Project… Gill visits a benighted village called Koraro, chosen to be one of Sachs’s so-called Millennium Villages, which were meant as demonstration projects to prove that foreign aid can really work. He asks a local man whether he has ever met Sachs, to which the man replies, “I have met the owner twice,” which in itself is worth a dozen U.N. development assessments and a hundred NGO field reports. And when Gill himself finally meets Sachs, he discovers that he, too, is grasping at the Chinese straw. “They are doing something,” he tells Gill, “where we are not there at all.” But Sachs also says that “unless the fertility rate comes down sharply I’m running out of ideas.” When Gill tells him that Ethiopia’s population has doubled in a quarter-century and will likely double again in the next twenty-five years, Sachs can only reply that “it is absolutely unmanageable … beyond any of our [development] tools right now.”

asking people what they think (and want) (II)

in responding to a recent article about the Kony2012 debacle, Bill Easterly pointed out that “NGOs should screen advocacy material with beneficiaries.”

though i tend to be more on the research than the service delivery or advocacy end of work, i fully agree. of course, intended beneficiaries – and other stakeholders – should be consulted about the content of the programs, goods, & services offered (before they are offered) as well as the advocacy materials. given how research and programs are currently planned, such efforts will almost always involve more time and more money. it will also likely complicate the narrative and, unfortunately, the Kony2012 movement seems to show that people respond to a simple narrative (and/or a simple solution — it’d be great to see more efforts in parsing out whether we can tell a complex story, coupled with relatively simple action steps (such as they exist), and still see positive public response)

we need a paradigm shift so that consultations at all phases of research/program design, implementation, & evaluation become the norm, not the sometimes-icing-on-the-cake.

if something along these lines is not in an NGO code of conduct, it really needs to be.

a quick quote from the article:

a group screening a popular video about fugitive African rebel leader Joseph Kony suspended showings in northern Uganda after angry viewers pelted members with stones and callers to radio stations objected to the portrayal of victims in the conflict…


wax prints (holland cloth)

A recent article came up about ‘African’ or ‘tribal’ prints.

I wrote a bit about this while I was in Ghana: Cloth is a big deal in Ghana – every Friday is traditional cloth Friday and many employers have a special organizational print available for employees to purchase.  For women’s clothing, cloth comes in two main varieties – wax prints and batiks.  I prefer the batiks, as the fabric is generally softer (I was told that batik is the English word; locally, it is known as ‘tye and die’).  I have found a few nice places (and the egg sandwich lady said that she will take me to her favorite place when I have time (“That would be great, when do you close your shop?”  “Oh, that doesn’t matter, we’ll just go!”)) and a great tailor named Pearl.

The wax prints are quite pretty (though sometimes you unfold a piece of fabric all the way and learn that what at first just looked like a nice design includes stranger things, like chalkboards or hands or other unexpected images).  They are, however, often heavier and stiffer, which makes them suitable for many of the two-piece dresses that local women wear (or, more likely, the style developed because the fabric was stiffer) but not necessarily appealing to me.

Fewer and fewer of the wax prints are made in Ghana and are rather being imported from China.  Interestingly, some of the most venerated fabric comes from Holland, also by an initially Eastern route.  How, precisely, a Dutch cloth-house founded in the 1840s (Vlisco, in the Netherlands) has come to be the premier fabric in West Africa is still somewhat unclear to me but I have pieced some things together thanks to the magic of the interwebs.  According to the timeline on the Vlisco website (which also has lots of pretty pictures), initially the company mimicked the prints of Indonesia (Dutch East Indies) and exported their fabrics there.  In the 1870s, they began exporting to West Africa as well, where apparently the “eastern” designs had developed some cache.  The site attributed the West African familiarity with “eastern batik” to “the return of African soldiers from Indonesia between 1837 and 1872.  These soldiers settled primarily in Ghana.”  Who were these soldiers?  Evidently, the Royal Netherlands East Indies Army, decreed in 1830, was populated by Dutch volunteers (national conscription was not allowed) and by mercenaries from Europe (Switzerland, Germany, Belgium), from the East Indies and from Gold Coast.  These troops played a large role in the Padri, Java and Aceh Wars.

Despite its growing popularity (and the growing importance of the West African market to Vlisco after competition became steeper in Indonesia), no director bothered to go to West Africa until the 1930s.  The African market became increasingly important to Vlisco after the 1950s and became its only market after the 1980s.

asking people what they think (I)

this is only a small splinter off my much larger soapbox of “why don’t we ask a multitude of stakeholders at all levels what they think and why they think x program did/not work?” but… check it out.

instead of channeling the world’s poorest citizens through malfunctioning microphones, I am proposing a radical, yet extremely simple, approach. let’s just ask them. not through some kind of “inclusive” process where a handful of token representatives have a chance to speak their minds. no, that is hardly better than what’s currently on the table. we should ask the masses directly.

organizations like Afrobarometer already do this in sub-Saharan Africa. their surveys ask households across the demographic spectrum to state their most pressing concerns. And, some of their responses might surprise you. for example, poor infrastructure (e.g. roads and power) is the biggest concern for roughly one in five households in sub-Saharan Africa. just one in 20 say that health is their biggest concern, while education is even less important. who would have known? we need to build upon these existing efforts with a more targeted survey specifically for the MDGs 2.0 debate – which would be standardized across the developing world.

sign me up.

rethinking the use of the word ‘simple’ in global health (II) – asking the right questions

i am not saying this is going to be all-time best solution (ha! ors pun!) but it does seem to be the result of asking the right questions, which include, if this (ors(+zinc)) is such a ‘simple’ intervention (in this case, meaning low-tech and cheap), why is not being taken-up?

it is not clear to me that the question was asked to all the right people. who, for example, answered this question by suggesting that supply chains and lack of suitable water were the main hindrances to the use of ors and, by implication, reducing child mortality from diarrhea? smart people, perhaps, and even people ‘on the ground’ but… it is not clear that anyone asked local people (anywhere – but in this case zambia) why they don’t use ors now.

if they did and the answer had to do with lack of clean water, awesome. if they did and the answer was something else, slightly less awesome. and, if they didn’t ask, less awesome.

there is plenty of discussion about stimulating demand among potential consumers — but that’s different than understanding why demand is not presently there, which may or may not have pointed to other ways of addressing the problem.

more here.

contraception, women, society – why are we (still) having this conversation in the US???

plenty has been said about this, so i am going to highlight the points of a few others. but the whole frame of the present national media and political conversation is infuriating. forgetting all the convolutions involved in saying that, in proposing an insurance mandate, anyone is asking anyone to use their taxpayer dollars to pay for them to have sex (and therefore give them the right to watch) or the weird suggestion that use of the pill, like condoms or plan b, would increase with the number of sex acts…

1. hormonal contraception does have health benefits beyond preventing pregnancy, which should be considered more seriously than is allowed in the present debate.

2. allowing people to have sex without the potential outcome of a pregnancy if that is not desired – and, ideally, also without the potential outcomes of sexually transmissible infections – is a really good idea for a society.

(we could argue fertility rates have fallen too far in some OECD countries – in part because of delaying the beginning of childbearing through the use of contraceptives – but that is so far removed from the present media debate that i’ll mostly leave it. that said, in the whole ‘yay society’ theme of this post in terms of how we treat women and sex and choices, it is worth noting that the antidote to sub-replacement (or lowest-low) fertility seems to be “encourag[ing] women’s labor market participation and the opportunity to reconcile work and family life. [these have] emerged as a key factor of the fertility rebound in a context of high female employment. this factor partly explains the reversal in the relationship between GDP per capita and fertility.” so, you know, let women/couples have kids when they’re ready and then help them & their families out a bit)

people are having sex. including teenagers. in the US.

teenage births, along with other factors, are an important indicator of future opportunities for women to pursue education and of career prospects. young mothers are more likely to drop out of education and work in low-paid jobs with long-term consequences on family welfare. the Adolescent Fertility Rate or Teenage Birth Rate is defined as the number of children born alive to women aged 15-19 per 1000 women of this age range. in all OECD countries for which data is available the teenage birth rates have decreased over the last twenty five years. at over one-third of the female adolescent population, the rate is especially high in the United States, Turkey, Chile and Mexico.

(there is nuance and debate around whether teenage pregnancy is detrimental and to what degree – nuance to which we should be attentive. to wit: “the broader society is selective in its attention to the actual life chances of urban African Americans and how these chances shape fertility-timing norms, in part, because this selective focus helps maintain the core values, competencies, and privileges of the dominant group. delayed childbearing is an adaptive practice for European Americans and an intensely salient goal they have for their children. yet early fertility-timing patterns may constitute adaptive practice for African American residents of high-poverty urban areas, in no small measure because they contend with structural constraints that shorten healthy life expectancy. European Americans put their cultural priorities into action ahead of the needs of African Americans and employ substantial resources to disseminate the social control message meant for their youth that teenage childbearing has disastrous consequences. their ability to develop a more nuanced understanding of early childbearing is limited by their culturally mediated perceptions. thus, cultural dominance can be perpetuated by well-meaning people consciously dedicated to children’s well-being, social justice, and the public good. the entrenched cultural interdependence of and social inequality between European and African Americans leads African Americans to be highly visible targets of moral condemnation for their fertility behavior, and also sets up African Americans to pay a particularly high political, economic, psychosocial, and health price.”)

abstinence-only education – which means education in which abstinence is the only thing taught, not that education under other labels doesn’t promote abstinence as a desirable outcome – doesn’t work all that well in the US or elsewhere. i mention this because a lot of the conversation seems to be focused on the decision to have sex or not, which really isn’t the decision a lot of people are making. the decision is whether or not to have sex safely and with intention toward the outcome. deal with it.

these data show clearly that abstinence-only education as a state policy is ineffective in preventing teenage pregnancy and may actually be contributing to the high teenage pregnancy rates in the U.S.

yay for society. at least, what i think is a reasonable goal for society. this nytimes article gives a nice summary of the links between contraception, labor market participation, & economic development – and plenty of links for further reading.

there is a wealth of economic evidence about the value of the pill – to taxpayers… as well as to women in general.

as the economist Betsey Stevenson has noted, a number of studies have shown that by allowing women to delay marriage and childbearing, the pill has also helped them invest in their skills and education, join the work force in greater numbers, move into higher-status and better-paying professions and make more money over all.

the pill also helped make the marriage market “thicker,” they write. by decoupling sex from marriage, young people were able to put off getting married and spend more time shopping around for a prospective partner.

those changes have had enormous impacts on the economy: increasing the number of women in the labor force, raising the number of hours that women work and giving women access to traditionally male and highly lucrative professions in fields like law and medicine. such trends have helped narrow the earnings gap between men and women. indeed, a study by Martha J. Bailey, Brad Hershbein & Amalia R. Miller suggests that the pill accounted for 30% of the convergence of men’s and women’s earnings from 1990 to 2000.