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A few thoughts and associated links on the Great Disruption Debate of 2014, triggered by Jill Lepore’s scathing indictment of the theory of disruptive innovation in this week’s New Yorker:

  • The theory of “Disruptive Innovation” is a very narrow one, and pretty easy to understand: upstart companies produce cheaper, less-”featured” products that reach customers who otherwise could not afford the more expensive product or don’t need all of the features. Over time, the upstarts produce slightly better, slightly more expensive products, which eventually begin to compete with the incumbents’ products, and often overtake them – eventually. Hewing closely to this definition, AirBnB is a disruptive innovation (using technology to offer a theoretically cheaper, inferior product to a hotel room), but Uber is not (Uber is a better, more expensive offering to traditional taxis – though you could argue that Uber is actually disrupting the personal car)
  • Most individuals and companies opining about the need to “disrupt” this or that aren’t referring to the theory; the term has been watered down and broadened to include basically any type of innovation. The article both outlines this trend and exemplifies it; Lepore, for example, counts the financial innovations that helped stoke the financial crisis in 2008 (e.g., collateralized debt obligations, mortgage-backed securities) as “disruptive innovations,” but it seems fairer to count them only as “innovations.” Not all innovations are disruptive innovations, and not all “disruption” is disruptive innovation (Uber is certainly disruptive in the colloquial sense of the word)
  • Apropos of the point above: Taco Bell doesn’t really need a “resident disruptor” because it already churns out the cheapest, shittiest tacos available. In Christensen’s parlance, the Doritos Locos taco is a sustaining innovation (Taco Bell is making what is theoretically a “better” taco), not a disruptive one
  • The article misses the point when it comes to “disrupting” people-centric industries like education, health care, and journalism, arguing that these are not disrupt-able because they have non-financial “obligations” and are, therefore, not “industries.” This is simply uninformed. For example, Massively Open Online Courses, or MOOCs, are routinely derided for being a poor alternative to on-campus learning – and that’s the point. MOOCs are, so far, a cheaper, inferior substitute for on-campus learning – but they meet the needs of some people. Over time, they’ll get better and more expensive, and more people will use them. They are, definitionally, a disruptive innovation
  • Lepore weakens her argument by including a strange you-damn-kids-get-off-my-lawn paragraph about kids and their scooters and their jeans and their coffee machines – preferring, presumably, the cold professionalism of a sclerotic newsroom to a more comfortable working environment
  • Regardless of the virtues or vices of Lepore’s article, this interview with Clayton Christensen (author of The Innovator’s Dilemma and the man who has done the most for – and gained the most from – the theory) is really, really strange. Christensen, a professor at Harvard, is generally regarded as a pretty nice guy, but the interview is rambling, angry, and sees Christensen use the third person instead of the first
  • It was simply irresponsible journalism for Lepore to not interview Christensen for the article, as Christensen claims
  • Will Oremus wrote a very entertaining mini-rebuttal to Lepore’s article: “Lepore’s main point is that disruptive innovation isn’t all it’s cracked up to be. At least, that seemed to be her point up until the point where she started talking about journalism”

Book-Blogging: The Great Escape, by Angus Deaton

TGE

The past two hundred years have borne awesome changes to the world (in the definitional sense of the word): world population has septupled – septupled! – and, looking at the way lives are lived now, anyone living in 1814 would likely conclude (not wholly incorrectly) that we are Sorcerers Practicing Black Magick. Technologically, socially, and economically, the past 200 years have been vastly different than the preceding 200. Or 1,000, for that matter.

How did a few nations break thousands of years of (relative) constancy and become significantly wealthier and healthier than ever before? Why didn’t, and haven’t, others? What’s happening now, and what can we expect to happen in the future?

Angus Deaton, a professor at Princeton University, wrote a masterclass of a book, The Great Escape, dissecting these questions. I can’t recommend it highly enough to anyone interested in health and wealth; medicine and economics; the past and the future.

The book isn’t actually a book; it’s more like a book and a chapter-length op-ed, and it’s worth reviewing each separately. The book, Chapters 1-6, is the most complete accounting of the recent changes in health and wealth in the world that I’ve read. The op-ed makes the case that foreign aid weakens recipient governments – especially in Sub-Saharan Africa, where in many countries it approaches three-quarters of government expenditures – and as a result harms the people it putatively tries to help (though “tries to help” does a lot of work in that sentence, and Deaton argues it often isn’t about helping them but us).

The first few chapters walk through the truly shocking increases in health many wealthy societies have witnessed during the past few generations. This “aging of death,” as Deaton delightfully calls it, started around the 1850s in Western countries and eventually filtered down to less-developed regions in the 1950s and thereafter; it continues to this day.

As Deaton points out, life expectancy is a confusing metric, and kind of a bad one at that. Take the fictional country of Macronesia: because of a genetic defect, half of its population dies at birth, and half lives to be 100 years old. It’s average life expectancy is, therefore, 50 years – but no one lives to be just 50, and those that make it past their first day have 100 years of life left. 50 is, in this context, a meaningless number. But it’s Macronesia’s life expectancy just the same.

And so it is with many real countries that have intolerably and unconsciously high infant and child mortality rates. Think America at the turn of the 19th century, when life expectancy was something like 40 (a generous, speculative figure that is almost certainly on the high side). But that’s because so many kids died. To pull a few (admittedly non-random) examples of lifespans we would consider long today, George Washington wasn’t 40 when he died; he was 67. Benjamin Franklin, John Adams, and Thomas Jefferson were 84, 83, and 90, respectively.

(Because I just have to: in one of history’s great coincidences, Adams and Jefferson – one-time sworn political enemies who nevertheless developed a long, deep correspondence by pen in the gloaming of their post-presidential lives – died on the same day in 1826 – the Fourth of July. The 50th anniversary of the official signing of the Declaration of Independence. Because of course.)

Another problem with life expectancy: as an American white male, my life expectancy at birth in 1987 was 72.1 years – but that was an outdated figure almost as soon as the ink dried on that year’s actuarial table. Changes in medicine, technology, and policy over my lifetime will almost certainly mean that my (American, white, male) peers and I will live, on average, far longer – even past 100.

Though he (rightfully) questions the use of life expectancy as a metric in and of itself, the massive uptick in it is because far, far fewer children are dying than before, and that this is because of public health measures:

The major credit for the decrease in child mortality and the resultant increase in life expectancy must go to the control of disease through public health measures.

Because of public health measures, when we talk about countries, we no longer talk about neonatal and child deaths per 1,000 live births; we talk about them in numbers greater than that by two orders of magnitude: 100,000.

As a result, in America, life expectancy increased from 47.3 in 1900 to 77.9 in 2006. He puts it more colorfully than I could:

One way in which the transition is sometimes summarized is to say that diseases move out of the bowels and chests of infants into the arteries of the elderly.

The second half of the book describes the unprecedented economic growth that began in the 1800s and continues today. I won’t get into it much (if there’s any story here you already know, it’s this one), and only will make a few points about measurement.

Deaton convincingly argues that defining and measuring poverty across countries is much more difficult than most casual observers realize. A dollar goes further in India than in the states, and even the calculation to account for this – the wonkily-named “Purchasing Power Parity” – is flawed in obvious and predictable ways. Defining poverty is also difficult in America itself; the poverty line was first chosen then rationalized, and has always been politically fraught.

Gross Domestic Product, or GDP, is a problematic measure, too (and a recent one, as Planet Money helpfully discussed on a recent podcast episode). As Robert F. Kennedy pointed out, it measures much of what we don’t necessarily want, and little of the important, ephemeral things in life.

(Deaton doesn’t even dive into the difficulties about figuring out the GDP of a country – especially a poor country – a monster of a problem in itself).

At times during the book part of the book, Deaton is a bit of a broken record – mentioning too many times to count that “escapes leave people behind, and luck favors some and not others”– but this is a minor sin easily overlooked.

The op-ed at the end is, to put it mildly, polarizing. Deaton is an intellectual monster in the field of development economics, so his firmly planting a foot in the “anti” camp made waves. I won’t get into the arguments much – there’s simply too much to cover – but will give a short summary and a note of admiration.

USAID Food Bag

His argument basically rests on the idea that foreign aid – even the 100% benign, apolitical aid, if it exists (though there’s reason to believe it doesn’t) – necessarily distorts the policies and actions of recipient governments. Governments that are strong don’t need the aid, he argues, while governments that aren’t strong (read: corrupt, authoritarian, or both) will be hurt by the aid. In other words, think of it like the Halstedian “radical mastectomy” of aid: it’s used when it either can’t help anyway or isn’t needed in the first place, and causes severe trauma either way.

(For more on radical mastectomies and cancer, read The Emperor of All Maladies, a wonderful book that I reviewed here).

Deaton does mildly argue that aid directed towards the provision of certain types of health care (safe water, sanitation, pest control) can be, on net, a capital-G Good thing. And he voices approval for certain types of indirect aid: funding research into Neglected Tropical Diseases; advocacy for policy changes that promote migration and trade; removing harmful rent-seeking subsidies; et cetera But overall, he’s quite skeptical of direct-to-consumer aid.

Deaton’s op-ed chapter is admirable for its bluntness and for its acceptance of a hard truth: getting rid of aid may be normatively the best for the long-term fate of low-income countries, but in the short-term this is both impossible – does anyone really think USAID and the World Bank are just going to disappear? – and has serious immediate consequences (people will die). But he argues for it anyway, and kudos to him for having the bravery to do so.

This book – and its accompanying op-ed – is fantastic. Full stop. Buy it now.

How a Blended Model Can Solve Some Market Failures (Part 2) – at NextBillion

Originally posted at NextBillionsee here for Part 1

Training on the Universal Anaesthesia Machine at Connaught Hospital in Freetown, Sierra Leone (photo: Steve Rudy)

Training on the Universal Anaesthesia Machine at Connaught Hospital in Freetown, Sierra Leone (photo: Steve Rudy)

A bit of background is necessary to help illustrate how we use this foundation-owned social enterprise model. In the 1990s, a British anesthesiologist working in Malawi, Dr. Paul Fenton, created the Universal Anaesthesia Machine (UAM) in what was a textbook case of necessity birthing invention: When the electricity cut out or the supply chain failed to provide oxygen canisters on time, the conventional anesthesia machines he used to provide anesthesia wouldn’t work. Without the ability to provide general anesthesia, some surgeries couldn’t be performed and patient care suffered.

The machines Fenton had on hand weren’t designed to function in such an environment. So he built his own anesthesia machine that would function without electricity or compressed oxygen, and the forerunner to the UAM was born.

Later, Fenton partnered with a foundation to refine his design. Market research and clinical feedback confirmed what he and his colleagues intuited: There was and still is an enormous need for a device like the UAM in many low-income countries and resource-constrained hospitals around the world.

With a compelling product on its hands, the foundation had to decide how to get it to hospitals around the world. For a variety of legal and technical reasons (an entire future blog in itself), the foundation chose to begin by spinning off the idea into a separate legal entity, and Gradian Health Systems was created, with the foundation as its sole owner and investor.

Like any organization, we have a limited budget and we use it to maximize the return on investment. But the foundation judges its success based not on how much profit can be generated but on the “extra-financial value” created – known in philanthropic circles as the “social return on investment” (SROI). The more people that have access to safe surgery and anesthesia through the use of the UAM, the higher the SROI.

Early on, we decided that donating UAMs was an inefficient way to produce this SROI; our impact was constrained by the number of machines we could donate based on a yearly budget. Demand exceeded supply.

So we chose to use a model that allows us to scale according to demand: selling machines at their marginal manufacturing and shipping cost. This frees up our philanthropic funding to build out a potential market for the machine and address the post-sale market failures described above.

Like a traditional business, we’re investing in the creation of the market by spending money up front – on marketing, research and development, international quality certification and the like – to drive future sales of the machine. Unlike a traditional business, we don’t expect to recoup that cost; it’s paid for with philanthropic funding so that we can offer the machine at as low a cost as possible – an important factor in hospitals’ buying decisions.

Crucially, the foundation’s investment allows us to address the market’s failure to address the post-sale needs of the customer: robust machine training for clinicians and biomedical technicians; easily accessible, open-source spare parts that can often be procured locally; timely maintenance and repair backed by warranty. Using philanthropic dollars ensures that these critically important components will be high quality and ubiquitous, even if they aren’t profitable.

To be sure, these components are expensive, but they are vital to ensuring the provision of safe surgery and anesthesia and, to our customers, produce the highest and longest-lasting SROI.

The idea of a foundation owning a commercial entity seems to be a novel subset of venture philanthropy that offers any number of exit options: the social enterprise could spin off as a for-profit, a nonprofit, or could stay a long-term investee of the foundation. Ultimately, this decision simply depends on the aims of each organization and the needs of the customer.

Whatever the decision, it’s critical that the foundation and social enterprise commit to one another; it would challenge the sustainability of philanthropic investment to, say, have the foundation simply stop funding at the wrong time.

And this model isn’t right for every situation. Foundations should not waste fixed philanthropic dollars on markets that aren’t failing, and some philanthropic solutions simply can’t rely on a market to offer goods and services. But it can be an effective solution when, as in our case, a market exists but is largely failing to serve the customer.

Foundation-owned social enterprise is a novel philanthropic model that has the potential to help solve market failures in a variety of contexts. It’s so novel, actually, that we don’t know of many other instances of its use; if you know of an organization doing something similar, let us know.

 

How a Blended Model Can Solve Some Market Failures (Part 1) – at NextBillion

Via NextBillion:

 

An operating theater at Connaught Hospital in Freetown, Sierra Leone (photo: Steve Rudy)

An operating theater at Connaught Hospital in Freetown, Sierra Leone, using the Universal Anaesthesia Machine (photo: Steve Rudy)

My organization, Gradian Health Systems, uses an atypical business model to get our product into the hands of those who could benefit from it.

We produce a unique medical device, the Universal Anaesthesia Machine (UAM), which is designed to provide anesthesia in any environment ­– including infrastructure-poor hospitals that lack consistent access to electricity or compressed oxygen (necessary to run typical anesthesia machines).

The model we use to manufacture, sell, distribute and support the UAM, foundation-owned social enterprise – more technically, a limited liability corporation wholly owned by a 501(c)3 private foundation –  is a novel means to combine the best features of philanthropy with the best features of business. It allows us to serve as a commercial entity using market mechanisms to sell a product, and as a nonprofit using philanthropic dollars to address significant market failures.

To understand why we use this model, you really need to understand the challenges that low-income country markets create for medical equipment manufacturers and why conventional models haven’t worked.

In high-income countries, medical device manufacturers have developed an effective and lucrative business model predicated on accessing multiple revenue streams. As you’d expect, the initial sale is one such stream, but lesser-known complements are the sale of a high-margin, long-term service contract and the recurring purchases of (often proprietary) spare parts and consumables.

And the model works. In these markets, strong infrastructure and a robust supply chain ensure comparatively low prices for proprietary spare parts and consumables – all of which hospitals can afford. Just as critically, facilities and regions have a deep supply of highly trained biomedical engineers to fix the often quite intricate and sophisticated devices.

In low-income countries, though, a dearth of hard and soft infrastructure strains this model to its breaking point. To take just one concern, it can be very difficult to find biomedical engineers trained to maintain and repair intricate and sophisticated devices; there are nine in Malawi, for example. Bringing in outside expertise is a time-consuming and expensive process, leading to long inoperability periods and high costs for already cash-strapped hospitals.

And all of this assumes that the product is right for the environment, which, as I’ve discussed before, simply isn’t the case for low-resource environments. Even if a hospital can pay for spare parts, consumables and repair, a machine that requires compressed oxygen still won’t consistently function in a hospital that often runs out of it.

Organizations not seeking to profit when trying to fill this gap have thus far generally failed to do so in a cost-effective and sustainable way. The most common model we’ve seen to address this low capacity to pay is to donate used, second-hand equipment (which I’ve written about previously for The Atlantic).

This donation model is problematic for two reasons. First, like the new, for-sale equipment described above, most used, donated equipment simply isn’t designed to function in infrastructure-poor environments. And second, sometimes donated equipment is positively ancient and simply should not have been donated in the first place; an old, out-of-production machine likely won’t have spare parts or consumables in production, making them more difficult to source.

The end result of these models is a staggering percentage of inoperable medical equipment in low-resource environments. Estimates vary, but 40 percent to 80 percent of medical equipment in sub-Saharan Africa is considered non-functional.

This makes us believe that there is a significant market failure in the manufacture and sale of medical devices in low-resource countries; improper devices are being sold or donated and are largely failing to serve the communities in which they’re placed.

We think it’s time for a new solution.

Foundation-owned social enterprise remixes conventional for-profit and nonprofit models to create something new.Combinatorial creativity at its finest, the model draws on the best of both business and philanthropy to sustainably address old problems.

 

Treating the Physical and Emotional Wounds of Obstetric Fistula in Tanzania (ThinkAfricaPress)

Obstetric fistula repair patients at Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT), a large disability hospital in Tanzania. Photo credit: Benjamin English

Obstetric fistula repair patients at Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT), a large disability hospital in Tanzania. Photo credit: Benjamin Eagle

Via ThinkAfricaPress

DAR ES SALAAM - Last fall, Agnes, a 26-year old hairdresser living in Mwanza, Tanzania, was pregnant with her second child.  She went into labor on the way to visit family in the south of the country and rushed to the nearest public hospital.

It was like too many public hospitals in Tanzania: overcrowded, under-resourced and understaffed. Alone and unexamined, she had a relatively common birth complication – obstructed labor – but wasn’t noticed, or cared for, by the too-few nurses on shift. After an agonizingly long time in labor pain, she was finally examined, and scheduled for an emergency caesarian section. The procedure was a success, and her new baby girl, Aditha, was born.

But because her obstructed labor wasn’t dealt with timely, an obstetric fistula – a hole between the birth canal and the bladder (known as VVF) or rectum (RVF)– formed. The caesarian section probably saved Aditha’s life (most babies born during obstructed labor do not), but it was too late to prevent Agnes from the physical and social consequences of an obstetric fistula.

Her doctor recommended she go to Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT), a large, disability hospital in Dar es Salaam known for its fistula repair operations. After her caesarian section wound healed sufficiently, she did.

CCBRT, a 230-bed hospital set up as a public private partnership with the Tanzanian Ministry of Health, is nothing like its public peers. Its walls are painted with pictures of animals and disabled children; the wards are quiet, calm, bright, and well ventilated; the place just feels clean. There’s even a playground for kids to play on.

I spoke with Agnes in one of the two obstetric fistula wards – a bright, inviting space filled with a number of nurses chatting with patients. Sitting on her bed in a blue hospital gown with Aditha playing at her side, Agnes told me what life was like with an obstetric fistula. Constantly “wet” from the urine and feces that uncontrollably leaked out of her, she couldn’t resume her normal life. “I could not go for weddings, I could not work. I felt bad. It was isolating,” she said. Her normal life was effectively over.

Physically, “a woman with a fistula will leak urine or feces or both,” Dr. D’Mello, an obstetrics and gynecology specialist at CCBRT, told me. As unpleasant as always being “wet” would be, the social and cultural symptoms of the disease may be worse. Like Agnes, they are shunned and isolated by their friends and family members.

Patients at CCBRT. Photo credit: Benjamin English

Patients at CCBRT. Photo credit: Benjamin Eagle

They’re also stigmatized. “[Women] are told the myth that surrounds fistula – that you have been unfaithful and this is a punishment for being unfaithful,” Dr. D’Mello said. “So admitting that you have a fistula is kind of opening up this whole stigma… so even declaring that you have a fistula is really not acceptable.” (Agnes asked that her full name not be used and that I not take her photograph out of concern that her neighbors and relatives may learn about her condition)

This is changing in Tanzania, though. The President of Tanzania, Jakaya Kikwete, has been vocal about the need to treat fistula patients humanely: “Society should understand that it is curable. We should stop shunning women suffering from the condition but instead encourage them to come out for treatment.” According to Dr. D’Mello, this and other efforts have been successful at partially reducing the stigma Tanzanian women with fistula face.

The World Health Organization estimates that worldwide, two million women currently live with obstetric fistula, with 50,000 to 100,000 women developing it each year. It’s a disease borne of poverty and lack of access to appropriate maternal care; the global burden falls entirely on women like Agnes, who live in poor countries with inadequate health care systems.

Tanzania, an east African country roughly the size of Nigeria, has 45 million people – only 360 of which are physicians. It has the fewest physicians per capita in the world, according to the New England Journal of Medicine: just 80 per 10 million people. Its neighbors – also severely lacking – have far more (see chart); South Africa and the United States have 95 and 300 times as many physicians as Tanzania, respectively.

Screen Shot 2014-05-22 at 12.40.15 PM

The supply of healthcare infrastructure – operating theaters, equipment, and trained staff – hasn’t nearly kept pace with demand in Dar es Salaam. Dr. Brenda D’Mello told me that when she worked at a large public hospital in Dar es Salaam, it was common to see “three, four, five, six women on a bed, every space in between filled with the women.”

“Women were delivering on the floor,” she said.

In urban settings, an obstetric fistula is a direct consequence of the available infrastructure’s inadequacy. A dearth of operating theaters, clinicians, and medical equipment forces physicians to constantly triage cases: “You would get people, women who needed a caesarian section, and they are more than one at a time, and there is one theater. So you end up numbering them by priority,” Dr. D’Mello told me. “The problem with labor: the woman is not going to die… so you can actually wait longer and longer and longer.” After the baby has died, the woman is unlikely to be the patient at highest risk, so she waits, and waits, and develops a fistula.

Improving hospital infrastructure and increasing healthcare staff capacity at the public and private level – to be sure, no simple task – will likely help prevent future fistula cases.  And it will make patients happier, too. Agnes told me that “there is a big difference” between public hospitals and CCBRT. “Doctors and nurses really care about the patients. The food is nice. Nurses are loving to patients.”

(It’s worth noting that nurses in public hospitals are loving to patients too – but at an under-resourced hospital where the nurse-to-patient ratio may be 1 to 10 on a good day, it’s a lot harder to show.)

Photo Credit: Benjamin English

Photo Credit: Benjamin Eagle

Incontinence resulting from the fistula causes another unique problem for patients: near-constant dirty hospital sheets. At CCBRT, though, Agnes told me, “I get fresh linens every day; when I soil [them] I get new ones. It’s a very clean environment.”

CCBRT provides care for patients with many types of disabilities: cleft lip and palette; burns; club foot; and more. Patients under five and women with obstetric fistula are guaranteed free treatment; middle-class and wealthy Tanzanians pay for the care they receive, which subsidizes care for the poor. Next year, a major expansion will allow it to deliver 15,000 babies per year.

But a few years ago, it found its surgeons ready but its beds empty: women weren’t coming to have the surgery, even though it was free to them (it costs the hospital about $415 for each fistula repair). One of the largest hurdles to providing fistula care is simply that women don’t know it is available; another is that Tanzania is a vast country, and getting from, say, Kigoma in the west to Dar es Salaam in the east is inordinately expensive for many women.

To mitigate these issues, CCBRT created a unique model that draws on a human-powered referral network; M-PESA mobile payment technology; and relationships with far-flung hospitals.

CCBRT’s Ambassadors are an integral part of the obstetric fistula repair program – a human-powered referral network for the hospital. About 550 former patients have been trained to sensitize their communities about obstetric fistula – and to seek out fistula cases (and other disabilities). When an Ambassador finds a fistula patient, she informs a CCBRT staff member, who uses Vodacom’s M-PESA mobile money platform to send enough Tanzanian shillings to cover the cost of a bus ticket.

Until 2012, patients were sent exclusively to the flagship hospital in Dar es Salaam, but thanks to funding from the Vodacom Foundation, CCBRT has assisted in the training and implementation of fistula repair programs in Kigoma, Arusha, and Moshi. Now, patients go wherever is closest, and are picked up at the bus station by a CCBRT staff member. The Ambassador is then sent a small “finder’s fee” of about 10,000 Tanzanian Shillings ($6) to cover the costs of transport and to serve as a small incentive.

This model has been an unabashed success. Before it began, in 2009, CCBRT did 163 fistula repair surgeries; this year, it did 713 (513 at the flagship hospital alone).

Whether or not she becomes an official ambassador, Agnes is likely to spread the word. “I expect to tell all women who have this problem to come to CCBRT,” she told me, unprompted.

I asked how she was feeling now, two weeks after her surgery. She flashed an enormous smile and said simply, “I feel good!” She’ll stay at the hospital for a few more weeks to ensure that the surgery was successful. She’ll spend some time with the women who have shared in her suffering, and then she’ll go home.

 

 

On Ethiopia

A few thoughts on Ethiopia that didn’t coalesce into full pieces.

***

On Good Friday, the stone churches of Lalibela are surrounded by reverence and cloaked in quiet piety. A sunny, windy afternoon finds hundreds draped in white cloth circumnavigating the first three of eleven churches, mostly sitting but occasionally standing to do a sort-of head, shoulders, knees and toes-like kneel-bow prayer a few times, always kissing the ground before rinsing and repeating.

Small children sit next to small elders, most of whom have likely made the pilgrimage to Lalibela more than 50 times. A few look like they could be on their 100th trip.

Outside one of the stone churches of Lalibela

Outside one of the stone churches of Lalibela

Every now and again, bells ring and chants emanate from the churches below. And they are below: the main entrance is on top of the giant rock that the first two churches were built from.

Built isn’t exactly the right word. The churches are more the final remnants of the rock that once contained them. As Michelangelo merely unearthed David from a slab or marble, King Lalibela merely unearthed these churches from a (much larger) rock – the holiest use of negative space, hammers, and chisels.

(According to legend and my guide, King Lalibela also had the help of 40,000 workers and a handful of angels that helped at night)

The parishioners sitting outside the churches have spent the day fasting, and many show it: slightly weak looking, maybe a bit slower to do their prayers. The fast ends at 5:00, and more than a few younger churchgoers sneak a look at their cell phones often enough to figure out that injera and shiro are on their minds.

***

Each country has a script.

In Uganda, it’s short and sweet: “Mzungumzunguhowareyoui’mfine” (all one word) followed by, after a short conversation, a (decidedly non-threatening) directive: “Give me money.”

In Malawi, it’s to the point: “You give me Kwacha?”

In Kenya and Tanzania, it’s often one word: “Pesa?”

If you’ve spent any time in east Africa, you’ve caught on and are remembering all of the times the script has been spoken to you. For the rest: the script is used by the Kid Asking For Something. There is diversity in each country’s script, sure, but the basics are pretty standard.

In Ethiopia’s tourist mecca, Lalibela Town, the script is long and eerily unchanging:

Kid: “Halloo?” (rhymes with Baloo, the bear from Jungle Book)

Hey.

Kid: “Welcome to Lalibela/Ethiopia.”

Thanks.

“Where are you from?”

The United States.

The Saturday market in Lalibela Town

The Saturday market in Lalibela Town

“Oh, the United States. Capital is Washington. Obamaland.”

Yep. (By now, you’ve realized that my part of the conversation is pretty uninspired.)

“What is your work?”

I work in hospitals.

“Me, I am a student. Grade 7.”

Oh, cool. Good.

“I am studying to become a doctor/engineer so I can help my city.”

Nice. That is good.

“Will you give me book? Pen? T-shirt?”

No, I won’t.

And that’s the end of the conversation. Occasionally the kid will say bye; often, he won’t, and he’s quickly off to find the next tourist to chat up.

Like most places I’ve been in east Africa, the number of kids and adults who just want to say hi and to ask how I am dwarfs the number that say hi to ask for something. Lalibela is definitely a special case.

But what’s concerning is that, like other touristy places, it’s possible the kids are being put to work by someone and aren’t enjoying the full fruits of their labor (or whatever you want to call it). This could be relatively innocuous: a sibling or a parent puts the kid up to it, and the kid does what he or she is asked – something like a chore.

The script is so standardized, though, that it feels like something a bit more sinister is occurring. It’s common in some areas for kids to be forced into this type of work – to become child laborers – for a “pimp” of sorts who uses them as income generators.

Internally, I lapse into an Eggers-style conversation with the kid who, in my head, is much more verbose and sophisticated than his or her slight frame and grade level would suggest.

But externally, my response is always the same: no, I won’t. This could be the safe move or the selfish move or both.

***

Addis Ababa is in its gawky teenage years.

The city is growing at an unbelievable clip. Without exaggeration, every street in the city has at least one building in the state of construction or renovation.

The entire city, it seems, is surrounded by the tree-branch scaffolding that marks a building in its gestation. Cranes are ubiquitous; so is cement, and noise, and directions speckled with “it’s next to the building under construction” (a little like saying that a place is next to the food cart guy in New York City.) Caterpillars drive down the street as if they were tractors in rural Minnesota – as if it were normal to drive a large industrial machine down the street. In Addis Ababa, it is normal to do so right now.

But like a gawky teenager in the throes and woes of puberty, the growth is awkward. Uneven. Painful. Moody.

Like any urban center, Addis Ababa is a magnet for those looking for a better life; the four million or so current residents are besieged by seekers who come in droves. And four million people is only a fraction of Ethiopia’s population, which is quickly approaching 100 million people (in an area about twice the size of Texas).

The prosperity hinted at by the construction boom isn’t distributed evenly and doesn’t seem to trickle down to the city’s worst off; the trickle down is more a trickle of a trickle that still only touches a few. Opportunity isn’t constructed as quickly as a new hotel or the new apartment building next to it.

And so there are more homeless, or semi-homeless, people than anywhere I’ve seen in east Africa. More hopeful and hurting and crippled and infirm citizens arrive to the city each day; they congregate in tourist centers and on sidewalks to ask for a few birr. Many have young children. Some have infants.

To be fair, the vast majority that come to the big city likely have something approaching a better life in Addis Ababa than they would have in a rural town bereft of opportunity, or electricity. But many – an unusually large group of people here, it seems – don’t.   And the massive economic growth of Addis Ababa (Ethiopia as a whole, really) has passed them, leaving them further behind.

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Ethiopian women are stunning.

***

I’ve come to recognize that the suffering of others affects me unevenly. Imprecisely. Idiosyncratically. Situations that should tear me apart don’t; things that could slip through the mind of anyone else stick with me.

Part of this, I think, is sheer overload; it’s simply too much for me to think about the desperation and deprivation of the countless Addis Ababa street mothers with their children running ahead of them or attached to them and street kids selling gum and polio sufferers dragging their useless legs behind them and elderly individuals standing on street corners and the countless nameless and faceless people I don’t see who are in the throes of need. The aggregation of the world’s pain would swallow me whole if I allowed it to.

There’s a theory at the periphery of autism research: severely autistic people are really just severely unfiltered. They don’t lack emotion, they’re drowned by it, and they tread water by controlling the world as much as they can. Everything becomes equally important, equally unmanageable; the barking dog, the body language, the bright lights, the vivid sounds, a person’s touch – all of it competes for scarce attention. The theory is known as the Intense World Theory (and is not without its critics).

This is kind of how I look at my experience disassociating from the pain of others. The metaphor is… fickle, sure, but I doubt I’m alone in feeling that way.

(Another part of this, it’s worth noting, is the total banality of seeing someone in distress; it’s sufficiently common to be wholly unsurprising. This is disgusting. Its only virtue is its veracity.)

But pain sneaks in through the relatively common stories of others. It seeps through the cracks.

Take Girma, a man who served in an Ethiopian opposition party; his eyes never stop sweeping the expansive hotel lounge we’re drinking coffee at, ostensibly in an effort to suss out the government agents listening in on our conversation (to me, our neighbors look utterly uninterested in us).

IMG_7366Girma (which is not his real name) left Ethiopia for asylum in a European country, only to find the prejudice thick and the opportunity thin. Seeking a better life, Girma tried to emigrate again, but other countries – including his most coveted choice, America – felt that asylum in one country was asylum enough. So he came back to his home in Addis Ababa, where the jobs were still scarce but at least there was family.

Now almost 40, he’s watched his friends and former political allies leave in frustration or fear; he’s seen them subsumed in a business culture that pays well but reeks of meek corruption. He refuses to capitulate to this reality; rent is twice his salary at a small organization in Addis Ababa, so he lives with his mother.

Though Girma is a warm and decent man, women don’t want to marry someone who “may not be around” in the future to raise children – someone, he notes, who could be disappeared or killed by the party in power with little reason and less warning.

Years ago, he was youthful, idealistic, and hopeful. He’s none of those things now.

Or take the woman who left her husband behind and took her two young children to America – not for a better life but for a better education. After completing a graduate program in one year, she returned to fight for the basic human rights of women.

Except the Ethiopian government has made it exceedingly hard for her, or anyone, to fight for the basic human rights of women. Colleagues fled the country, and though we’re dining socially, she can’t help but wonder if she’s next. She wonders if her kids will be OK if something happens to her.

She seems hopeful. But she seems scared, too.

Two faces of repression in Ethiopia: professional, passionate, and pained; heads bloodied but somehow unbowed. Stymied by autocrats held up by the world’s elite as leaders for the future of Africa. Just not the future of Africans.

And their stories shake me; their struggles bother me; their pain seeps in.