Some Nuggets From the Amber: Keshavjee’s ‘Blind Spot’

Just finished Salmaan‘s Blind Spot: How Neoliberalism Infiltrated Global Health. Below, a few tidbits of his weaving of the local and personal with the global, ideological, and ideal. everything below represents a direct quote and the page numbers are marked in parentheses.

This book is intended to add to the conversation about how to more effectively bring the fruits of technology and innovation to those for whom it is a matter of life and death; how social, political, and economic forces have shaped practices in global health; and how ideological blind spots are traps along the path of achieving some of our most humane and important societal goals (xxxii).

In truth, I was confused. I was in my mid-twenties and had been convinced by seasoned development experts that this approach [a revolving drug fund in badakhshan, tajikistan] was an integral part of the transition from “humanitarian assistance” to “long term development.” Of course, as a graduate student somewhat versed in development theory, I knew that something was not right about planning a strategy with people from France and Switzerland, whose medicines were paid for by health insurance, to convince the Canadians, whose medicines were paid for by health insurance, that the Bangladeshis, whose entire life-world had collapsed, who had no access to pooled-risk insurance schemes, and who were now living in poverty, should finance medicines from their destitute communities; that they should “participate in their own health” by joining committees that defined what doctors could prescribe for them; and that their system of curative care – with hospitals, clinics, and experts trained over 70 years of soviet rule – should move towards a more “preventative” medical system in the midst of epidemic disease and hunger. But I participated in moving the strategy forward because i saw it as a means of protecting the most vulnerable (82).

The rise of NGOs as recipients of aid dollars closely followed the ascendancy of neoliberal thinking in washington and london. in their studies of the ngo sector, David Hulme and Michael Edwards described the 1980s and 1990s as a period dominated by a “new policy agenda,” which placed a premium on the untested belief that the private sector was a better mechanism for delivering services and that NGOs are more efficient than the government, especially in providing services to poor people… NGOs became a powerful global political force explicitly identified as a meeting place for economic and political aid (106).

As Ahmed and I were to see, these assumptions did not stop with the revolving drug fund. Instead, it appeared to us that the idea that privatization was the only logical path forward – an assumption made without critical assessment of the potential consequences – was manifesting itself in other ways. It was as if the aspirations of Hayek and his colleagues at the Mont Pèlerin Society were being realized in real time: ideology was operating as common sense. as to other important outcomes – reduced mortality or morbidity, or ensuring justice and dignity – they fell into what I refer to as realms of neoliberal programmatic blindness: areas of programs that are eclipsed by ideological aims (114).

I have come to the conclusion that the way out of the amber is both complex and simple. At its most complex, it will require the re-calibration of our goals as a society and the type of world we wish to create… at its most simple, this will require re-calibrating our focus in global health and development from “sustainability” and “local ownership” to an approach that puts equity and patient outcomes first… a re-calibration of focus towards equity of access and equity of outcome will allow NGOs to again take up the mantle as a vanguard of a moral order that finds poverty and structural violence unacceptable (142).

how is a raven like a writing desk? (smartphones as sanitation metaphor)

i have raised my eyebrows once or twice here about some of the discussions on the ipad or smartphone of toilets and sanitation. now i have gotten through the @gatesfoundation challenge paper and have a few more things to say. i briefly summarize the three key topics of the paper in  terms of approaches to improving sanitation and then consider the extent to which a smartphone is a reasonable guide to a reinvented, universally appealing and affordable toilet.

first off all, the premise of the paper, in part, is that we have managed to meet the world drinking water MDG early, though i cannot find a clear explanation of how we did that. but, if we did, we have somehow found a way to bring water in without having it flow back out to carry away waste. are there any cool lessons we are supposed to have learned from successes in the provision of drinking water (despite the fact that gains are uneven, that they may not be sustained, etc) that can  be applied to sanitation or development efforts more broadly?

but the authors want to suggest that not having water to carry away waste is not a bad thing: not only is it the reality with which we have to deal for the foreseeable future (governments are not adequately setting up sewer systems, leaving TMNT homeless) and waste processing — but using large amounts of water to move waste to an energy-intensive plant may not be the soundest idea in general. the authors lay out three  main approaches to improving sanitation. first is the unfortunately acronym-ed* Community Led Total Sanitation (could we not have gone with CoLTS instead of CLTS?), which is about altering social norms around sanitation – open defecation in particular. communities strive to become open-defecation free communities (welcome to pleasantville! open-defecation free since 2008!). of course, behavior change depends on the maintenance of a viable alternative to open defecation – i.e. functional and pleasant toilet facilities. also, it is worth noting, as the authors do, that ‘open defecation’ can occur even when people use latrines; emptying the septic tank out in the open is the equivalent of just having gone in the open in the first place — meaning that open-defecation remains both an urban and a rural problem.

the second idea, which is linked to the third, is that toilets should be able to create useful products out of the waste, namely fertilizer and/or energy. linked to this idea of profit- or product-generation is the need to come up with better services for emptying latrines and processing ‘fecal sludge.’

the third idea also has to do with reconceptualizing the toilet – this is where the smartphone metaphor comes in. the idea (with prototyping currently funded by gates) is to come up with a cool toilet that not only will it be a reasonable technology for those currently without access to safe sanitation but it will become the new gold standard everywhere. because of it’s high water and energy use, the authors suggest, the water closet’s reign is – or should be – nearing an end.

i understand that the ‘smartphone of sanitation’ is nice because it is alliterative and rings of the birth-of-social-marketing-catchphrase, ‘why can’t we sell brotherhood like soap?’ it lets you talk about poop in the same way you discuss technology. the main point of the metaphor seems to be about toilets being designed and marketed as an aspirational item that, again, will become the new gold standard for everyone, as the authors say, “from sitters to squatters and washers to wipers” the world over.

it seems worth pausing to consider how toilets could be like smartphones. spoiler alert: i have not yet come up with a better metaphor, just starting the conversation.

first, what is currently the height of toilet technology? japanese toilets (further reading here.). these are presently the aspirational toilet, with a wide array of features and services — and it is probably aspirational in ways that a reinvented toilet would not be (since the new toilet designs are supposed to use less water and energy, assorted spraying and heating would seem to run counter to this).

how could a new toilet be like a smartphone? what works about this metaphor?

  • like the move away from landlines, the new toilets will be off-the-grid
  • it will be hard to remember how you ever lived without one & everyone will need/want one
  • the user scale will be at the individual or household level, rather than the community
  • the user interface and experience is emphasized — finally moving us to a conversation that we need to not only provide safe sanitation but pleasant sanitation that people will want to use (moving beyond it just being free of flies and unpleasant odors as criteria for satisfaction with sanitation)
  • an industry has grown up around the maintenance, transport, decoration, and so on, of smartphones
  • it may (?)  be able to overcome “issues of high cost, slow adoption, and limited benefits” that previous technologies have faced (suggesting that our present flush toilet model is the equivalent of fax machines and desktop computers and that we will leapfrog over it?)

but, part of why we buy smartphones are features that will likely never be captured in a toilet (perhaps my imagination is not sufficiently active) — and which we may not want to emulate.

  • part of the aspirational aspect of smartphones is that everyone is pulling theirs out all the time, so you get to see and be seen. they are a profoundly public and social technology.
  • there is an ever-proliferating pool of new apps and functions that smartphones can take on, making the phone constantly novel in some way.
  • smartphones can be tailored and customized in various ways
  • people can be bewildered by their phones (not me, of course) but the reinvented toilet is explicitly supposed to be “fool-proof” (echoes of birth control in the 1970s, anyone?)
  • if you run out of money or time to do maintenance (let’s say, topping up your phone with credit), it doesn’t become totally unusable — you can still receive calls & texts. but, if you forget to charge it, it doesn’t work
  • there is a constant desire to upgrade
  • they are constantly getting smaller

so, smartphones as the model for toilets work in some ways but not in all. even if we chat about the novelty of the japenese toilet on the first few trips to a fancy restaurant, in the end, toilets are fairly private and socially disconnected. and it is not clear that they need to be high-tech to be pleasant, safe, and useful. the ways in which we will make people want to invest in a new toilet will be quite different from the ways that smartphones have become desirable. though we may be able to harness nutrients and energy from waste in these reinvented toilets, there probably won’t be a constantly flow of new things that a toilet can do for us.

the comparison with smartphones may help us start the conversation about sanitation but it can’t completely guide us toward the toilet of the future. toilets may remain more like dishwashers and washing machines and vacuum cleaners, in which case, they may well need to be marketed towards moms – either to make their life easier or to help them care for their family better (whether or not you think that is an appropriate or fair marketing strategy for household appliances, it is certainly the strategy).  (happy belated mother’s day mom! i’ll get you a new toilet when they come out.)

remaining questions:

  • thoughts on must-have features for a new toilet, which may or may not have a smartphone parallel? 
  • also, if these are going to be the hip new toilet for everyone, how long do you think it will be before we BOGO toilet schemes pop up?
  • absent flushing toilets, how will dead goldfish get back to the sea?

*there really needs to be a business that checks acronyms and baby names/initials before anyone  makes final decisions on such things.


happy malaria day!

turns out, control means you are supposed to keep working at something (that includes funding it):