The “Misuse” of Bednets Shows the Need for More Community-Led Development

What’s worse: malaria, or hunger?

If you’re reading this, there’s a pretty good chance that you’ve never had to Would You Rather that question.

Millions of people, though, have to weigh the relative chance of their children getting malaria vs. not having enough to eat. Every day. As Jeffrey Gettleman writes in a long piece for The New York Times, many choose the former:

But Mr. Ndefi and countless others are not using their mosquito nets as global health experts have intended.

Nobody in his hut, including his seven children, sleeps under a net at night. Instead, Mr. Ndefi has taken his family’s supply of anti-malaria nets and sewn them together into a gigantic sieve that he uses to drag the bottom of the swamp ponds, sweeping up all sorts of life: baby catfish,banded tilapia, tiny mouthbrooders, orange fish eggs, water bugs and the occasional green frog.

And later:

For Mr. Ndefi, it is a simple, if painful, matter of choice. He knows all too well the dangers of malaria. His own toddler son, Junior, died of the disease four years ago. Junior used to always be there, standing outside his hut, when Mr. Ndefi came home from fishing.

Mr. Ndefi hopes his family can survive future bouts of the disease. But he knows his loved ones will not last long without food.

Emphasis mine. For those who haven’t used one before, this is what a long-lasting insecticide-treated bednet (LLIN) looks like (though they aren’t always pink):

A bednet at the Dive Inn, in Kampala

A bednet at the Dive Inn, in the Kabalagala neighborhood of Kampala, Uganda. Yes, the Dive Inn; worth every penny of the 10,000 UGX ($4) per night cost. (Credit: Mike Miesen)

When used correctly – as they almost always are – LLINs are an incredibly cheap and effective way to prevent malaria and the child deaths, anemia, and other issues it causes. That understates it; they are the best means of preventing malaria. Full stop*. GiveWell helpfully reports on the evidence supporting LLIN distribution here, and it has listed the Against Malaria Foundation (AMF) as one of best uses of charitable funds for the past few years.

But as Gettleman notes, sometimes people use LLINs in other ways, ranging from the sartorial (as a dress or veil) to the life-saving – just not in the way the global health experts assumed they would.

Because it turns out that LLINs are, well nets – and really cheap ones at that. They have incredibly small holes, meaning they’re great at catching small fish like these, from Lake Malawi:

fish like this

Fish drying on the shore of Lake Malawi. Fun fact: with some salt, they’re pretty good. (Credit: Mike Miesen)

For communities living on the shores of large lakes and small streams in east Africa, fish are one of the most reliable sources of calories – and, crucially, protein. They provide live-saving calories to children and adults.

And yet there are people that are shocked – shocked - that some choose to use the nets that “we” gave them to prevent malaria for fishing; that the nets are being “misused” or that “our” benevolence is spurned by ungrateful recipients.

This is misguided. Using LLINs for catching food rather than preventing malaria is an entirely rational decision; it’s so rational that nobody should be the least bit surprised.

The problem isn’t “misuse.” It’s poverty, an utter lack of opportunity. When there’s no work to be done, individuals and families – even entire communities – make do the best they can. They may sell the excess vegetables that come from their plot of land so they can afford school fees, or they may “hack” the LLINs given to them to prevent malaria into a net used to catch fish.

At a broader level, “misuse” is really just another way of saying that NGOs and multilateral organizations failed to do what they were established to do. They impose their answers onto communities, rather than simply ask those communities what they actually need.

This is why integrated, community-led development provides a better path to real and sustainable development. It refuses to tell communities what they need or to implement solutions that aren’t agreed on by the community. Community-led development looks different than top-down development, and so it scares a lot of development experts, many of whom think that communities need solutions brought to them.

So, what does it actually look like? Often, like this:

Spark

A community in Nyagisenyi, Rwanda. (Credit: Mike Miesen)

This is a community in Nyagisenyi, Rwanda, a chilly village near the edge of the country’s border with the Democratic Republic of the Congo and Uganda. The community is building a vocational school that will teach its children and young adults the skills to be seamstresses, carpenters, and more. The project is led, planned, and executed by the community, with support and facilitation from Spark MicroGrants, an NGO that provides small grants — just $3,000 – $10,000 — to entire communities. Spark MicroGrants places virtually no restrictions on the funds, provided that the community (women included) comes to consensus on a project.

Community-led development also looks like this:

GD

How one woman used the approximately $1,000 given to her by GiveDirectly. (Credit: Mike Miesen)

School fees, maize, some nails, a table with some chairs. This list is an accounting of how one woman in Siaya District, a mostly-rural area in western Kenya, used the approximately $1,000 given to her by GiveDirectly**. The innovative NGO simply donates cash, unconditionally, to poor individuals on the phone-based mobile payment system, M-PESA . They use it on whatever they believe they need most. A randomized controlled trial, the most robust and reliable study design, showed that GiveDirectly recipients disproportionately used the money on health and education and home durables – not on the tobacco and alcohol many development “experts” predicted. Those who received funds were, unsurprisingly, happier and less stressed.

The largest expense on this woman’s list is “mabati” – a metal roof. Previously, her home was made of thatch, which does its job pretty poorly. It looked something like this:

A home in Siaya district with a thatch roof. Thatch roofs are terrible at their job - they let in rain and need to be replaced every few months

A home in Siaya district with a thatch roof. Thatch roofs are terrible at their job – they let in rain and need to be replaced every few months. (Credit: Mike Miesen)

Now, her roof looks like this:

text

A home with a metal roof. According to everyone I spoke with, a metal roof is much better than a thatch roof, for a variety of reasons. Nearly every person I spoke with in Siaya district used GiveDirectly funds to purchase a metal roof. (Credit: Mike Miesen)

How many NGOs exist to provide sustainable roofing for communities? I can’t think of one. But every single individual I spoke with in Niaya district used at least a portion of their GiveDirectly funds on a roof.

This is not to say that the Against Malaria Foundation is doing a poor job. By all accounts, it is doing an outstanding job; it’s worth reiterating that almost everyone uses an LLIN as a means to prevent malaria. AMF is, along with the Schistosomiasis Control Initiative, the best counterexample to my argument***. But there are too few organizations like Spark MicroGrants and GiveDirectly, and too many that assume they know what is best for those they try to help.

*Here, I’m referring to immediately feasible means of preventing malaria. Eradicating malaria is feasible, of course – we did it in the states after World War II, using DDT – but difficult, and currently implausible (if not impossible) in much of the world. It’s a long-term fix; LLINs are a short- and medium-term patch. Other methods – like genetically modifying mosquitoes – are interesting but unproven for Anopheles gambie, the species that transmits falciparum malaria. And it’s unclear what the downstream ecological effects would be of eradicating mosquitoes in regions where they are native

**GiveDirectly is also one of GiveWell’s top charities

*** Also a top-rated charity by GiveWell, the Schistosomiasis Control Initiative (SCI) distributes de-worming pills to children in school

Gratuitous Photography Interlude – Santo Domingo, Dominican Republic

Independence Park in Santo Domingo

Independence Park in Santo Domingo

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A statue of Christopher Columbus

A statue of Christopher Columbus, a very, very awful human being

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Caribbean Sea

Caribbean Sea

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Calle Las Damas, supposedly the oldest street in the Western Hemisphere

Calle Las Damas, supposedly the oldest street in the Western Hemisphere

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fort Ozama

Fort Ozama

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Book-Blogging – Scarcity, by Sendhil Mullainathan and Eldar Shafir

Scarcity coverAs I’m writing this, it’s the middle of the holiday season, which means that you’re probably a little dumber right now. A bit more scatterbrained. Likely reaching for that extra holiday cookie or for one more egg nog than you really need.

Upon reflection, you’d probably admit that this is at least partly because you have a lot on your mind; more last-minute gifts to wrap than time; and, after purchasing a plane ticket home, buying gifts, and (over-)indulging with friends, a much thinner wallet. You’re stressed out.

In the parlance of Sendhil Mullainathan and Eldar Shafir, you’re experiencing “scarcity” – you’re “bandwidth-taxed.” In their excellent read, Scarcity, the authors seamlessly weave real-world examples with clarifying experiments to show just how pernicious scarcity can be. I highly recommend picking up the book; it will change the way you look at your finances and your time. And hopefully it will change the way you think about how poorly-aligned our society’s understanding of individuals in poverty is; how a reimagining of anti-poverty policy could make everyone – but especially the poor – better off.

As Mullainathan and Shafir point out, scarcity isn’t all bad; as anyone who has written a last-minute paper or crammed for a test knows, a time constraint provides a useful “focus dividend” – it gets you to get stuff done[1].

But the costs of scarcity often outweigh its benefits. A packed schedule or a bank account near zero (or below) cause tunneling: focusing on the most pressing issue, often at the cost of the long term. You take out a payday loan to pay the late bill, even if it leads to usurious interest rates you’ll have an even harder time paying off next month; all your meetings start 10 minutes late, and none of them are all that productive; you choke on that first date you really wanted to go well.

It’s not just your free time or wallet that are depleted, though; it’s your bandwidth – a wonky way of describing “brainpower.” The correct understanding of bandwidth, Mullainathan and Shafir argue, is akin to a gas tank; you use it up over time, and when you’re working on a thoughtful task, you use it up faster than when you’re doing something mindless[2].

And when your bandwidth is taxed, you are dumber. Literally. In one of Mullainathan’s and Shafir’s studies, mall-goers –some well off, others poorer – were asked about a hypothetical decision to spend either $150 or $1,500 to fix some short-term car trouble, and then were given a test of Raven’s Progressive Matrices to judge fluid intelligence.[3] When given the $150 hypothetical, the rich and poor looked equally intelligent; when given the $1,500 hypothetical, the poor did significantly worse. As the authors note, this was significant both in the statistical sense and in the real-world sense:

 Our study revealed that simply raising monetary concerns for the poor erodes cognitive performance even more than being seriously sleep deprived… our effects correspond to between 13 and 14 IQ points. By most commonly used descriptive classifications of IQ, 13 points can move you from the category of “average” to one labeled “superior” intelligence.

Thinking about money issues temporarily made people less intelligent, by nearly an entire standard deviation. Mullainathan and Shafir found similar effects to executive control:

 The same farmer fared worse on fluid intelligence and executive control when he was poor (preharvest) than when he was rich (postharvest). Much like the subjects at the mall, the same person looked less intelligent and more impulsive when he was poor… The postharvest farmers got about 25 percent more items correct on Raven’s. Put in IQ terms, as in the earlier mall study, this would correspond to about 9 or 10 IQ points

This is why, the authors note, “scarcity creates its own trap.” Tunneling, and the juggling it forces, distorts decision-making:

Scarcity, and tunneling in particular, leads you to put off important but not urgent things—cleaning your office, getting a colonoscopy, writing a will—that are easy to neglect. Their costs are immediate, loom large, and are easy to defer, and their benefits fall outside the tunnel. So they await a time when all urgent things are done. You fail to make these small investments even when the future benefits can be substantial.

You make dumb long-term decisions because you only think about the most immediate and pressing things to do.

A proper understanding of, and reckoning with, these ideas leads to significant individual, social, and political changes.

For individuals, it may mean scheduling high-bandwidth tasks earlier in the day, or at least not scheduling all high-bandwidth tasks back-to-back; perhaps you should put mindless tasks – doing expenses, maybe, or clicking through low-priority emails – after something that requires your full attention.  And it means trying to turn all of the hard, repetitive decisions you have to make into one-time decisions; you can either have to say no to the chocolate bar every time you open the pantry, or just say no to it once at the grocery store. Same deal with habits: if you go on a run or to the gym on a consistent basis, choosing to go today will be, well, less of a choice.

As a society, these ideas should lead us away from viewing the poverty problem as a moral one – thinking that those in poverty are lazy or dumb or what have you – to a practical one. We know – or, more accurately, have a strong factual basis to believe – that a bandwidth-taxed individual is liable to make worse decisions, and that those in poverty are, by definition, bandwidth-taxed individuals. Properly considered, the research should lead to a greater level of empathy; we all know what it feels like to be bandwidth taxed – but most of us are fortunate enough to not feel like that all the time. Many aren’t, though.

If you view poverty through this lens, it’s easy to see how specific policy changes could help increase bandwidth and reduce scarcity. One stark example: payday loans[4]. Mullainathan and Shafir put it better than I can:

Many workers, as we saw in chapter 5, resort to payday loans. Yet it’s worth observing that a payday loan is often simply a loan against work that has already been done. The worker who takes a payday loan halfway through the pay cycle has already earned half her paycheck. The need for a loan is largely due to the fact that payment happens with a delay. Why should an employer have workers taking these loans, potentially falling into scarcity traps, taxing bandwidth, and resulting in lower productivity, especially when the employer can himself give pay advances at low cost? How valuable would it be for employers to improve productivity by offering the right financial products and creating bandwidth?

This is a pretty nonideological solution to a politically-fraught issue. There are costs to it, sure, but as the authors point out, it’s easy to see how they could be outweighed by productivity benefits.

Finally, policymakers and policy wonks need to learn how to craft programs that take the already-limited bandwidth of the poor into account:

We treat education as if it were the least invasive solution, an unadulterated good. But with limited bandwidth, this is just not true. While education is undoubtedly a good thing, we treat it as if it comes with no price tag for the poor. But in fact, bandwidth comes at a high cost: either the person will not focus, and our effort will have been in vain, or he will focus, but then there is a bandwidth tax to pay. When the person actually focuses on the training or the incentives, what is he not focusing on? Is that added class really worth what little quality time he managed to spend reading or with his children? There are hidden costs to taxing bandwidth.[5]

Scarcity is a problem we all face, in one form or another. And we face it together, too, as a society. Read this book and you’ll have a much better understanding of it.



[1] Though, in those cases, neither the paper nor the studying is as good as it would be sans procrastination

[2] You may recognize this idea as “ego depletion,” Roy Baumeister’s model for how willpower is reduced when people are faced with difficult decisions. In this model, willpower is a muscle that can be used, depleted, replenished (with a sugary treat, say), and strengthened over time

[3] You know – and likely loathe – these:

Screen Shot 2014-12-23 at 9.56.48 PM 

 

 

 

 

 

 

 

[4] Speaking of which, the John Oliver segment on payday loans is excellent

[5] As an aside, if you’ve worked in international development in any sector, you recognize how difficult education/”sensitization” (for those in east Africa) is. Add bandwidth to the long list of reasons why.

Eight Podcasts to Fill that Serial-Sized Hole in Your Commute

Because selection bias, if you’re reading this I’m willing to bet you listened to, and loved, Serial.

Maybe you had never previously listened to a podcast before and picked up Serial halfway through, on the recommendation of a rabid fan. Maybe you heard it on This American Life. However you got to it, it’s over – at least for now.

Here are a few excellent podcasts to fill the Serial-sized hole in your Thursday morning commute. If you already listen to podcasts, you’ll almost certainly know the first few.

Radiolab

WNYC_Radiolab_logo.svgRadiolab is my favorite podcast, and one of my favorite things, period. Jad Abumrad and Robert Krulwich have consistently put out eminently re-listenable, curiosity-driven inquiries that rival the best efforts of journalists and entertainers everywhere. It has an extensive back catalog of episodes, so it’s the perfect companion for a long run/commute/bus ride.

Start With: Memory & Forgetting; Falling; Colors; Translation; Blood; Patient Zero

 

 

 

 

Planet Money

PM

Born from the 2008 financial crisis and This American Life, Planet Money is an economics-focused podcast consistently delivers entertaining, thoughtful, and edifying 15-20 minute episodes.

Start With: Just download the most recent two or three

 

 

 

 

 

The Memory Palace 

The_Memory_Palace_logoHost Nate DiMeo’s The Memory Palace highlights historical ephemera – entertaining vignettes that could be footnotes in your college history textbook. DiMeo has an uncanny ability to dredge up the fascinating, humanist, often-heartbreaking tales behind World Fairs, elevators, and the Civil War. New episodes are rare these days, but it has a long back catalog to pull from.

Start With: Picture a BoxAfter PartyDistanceSix StoriesLost LobstersSix Scenes from the Life of William James SidisGiants in Those DaysCrazy Bet

 

 

 

 

 

99% Invisible

99invisible-logo-1400

99% Invisible is all about design, and the little things that so blend into the background of our daily lives that we forget that they must have been made. Roman Mars is a remarkable storyteller, and this podcast will teach you to look at the daily stuff in your life differently.

 

Start With: Higher and HigherOctothorpe; Queue Theory; Future Screens are Mostly Blue; Reversal of Fortune

 

 

 

 

 

 

StartUp

Startup

In some ways, the most similar to Serial, StartUp (now Gimlet Media) is a, well, serialized look at starting a business. It’s hosted by Alex Blumberg, a great storyteller who was a founding member of Planet Money and a former producer for This American Life.

Start With: Episode One

 

 

 

 

 

 

 

Very Bad Wizards

VeryBadWizardArtwork+website

A philosophy and psychology podcast for a (smart, curious) lay audience. Tamler Sommers (a philosopher) and David Pizarro (a psychologist) are friends and have a natural rapport. They cover complicated philosophical concepts, but always in a way that is easy and entertaining to follow.

Start With: Trolleys, Utilitarians, and Psychopaths; Paul Bloom and the Perils of Empathy

 

 

 

 

 

 

 

The Gist

Gist

The only daily podcast I listen to, The Gist is hosted by Mike Pesca, an entertaining guy who was made to be a daily podcast host. He’s smart, funny, and clearly in love with the job.

Start With: yesterday’s episode

 

 

 

 

 

Slate’s Political Gabfest

slates-political-gabfestSlate’s Political Gabfest is a weekly digest of the most important stories in American politics. The hosts are informed, smart, and entertaining, and I learn something every episode.

 

Start With: last week’s episode

 

The New Yorker’s Article on Fecal Transplants is Excellent

Fecal bacteria sample

On Fecal Microbiota Transplant (FMT), from a recent (excellent) New Yorker article by Emily Eakin:

“Nothing in health care works ninety per cent of the time,” Mark B. Smith, a microbiologist at M.I.T. who is a co-founder of OpenBiome, the stool bank, told me. Zain Kassam, a gastroenterologist who is OpenBiome’s chief medical officer, put it this way: “It’s the closest thing to a miracle I’ve seen in medicine.”

This piqued my interest; as Darius Tahir put it on Twitter,


Pretty much. I’ve written about fecal transplants and the microbiome a number of times in the past few years – see here, here, and here, for starters – and am glad to see some of the same research discussed in this article.

Book-Blogging: Making of the Atomic Bomb, by Richard Rhodes

The_Making_of_the_Atomic_BombRichard Rhodes’s Making of the Atomic Bomb is not for everyone.

For starters, it’s long – really, really long.  It’s also fantastically dense, serving as not only a history of the atomic bomb but also as a history of nuclear science, anti-Semitism in eastern Europe, and of World War II. And it can be a slog – at times, a hard read and a boring one to boot.

But it is the book to read if you want to learn about, well, the making of the atomic bomb and the Manhattan Project.

For that reason, writing a review of it is pretty much unnecessary: either you’re the type of person to read this book, or you’re not. If you are, I highly recommend it; if not, I don’t think you’ll like it.

Instead, after the jump I’ll list a few of the sections I highlighted while reading on the Kindle, mostly because I thought they were interesting or provided a unique perspective or thought.

Life-Saving Poop, Now in Pill Form

Ingesting fecal material is an excellent way to pick up some pretty nasty diseases, like cholera, typhoid fever (as I can personally attest), and a variety of other diarrhea-causing agents that, together, kill 800,000 children five years or younger each year. That’s 2,200 child deaths each day. It’s horrifying.

But paradoxically, ingesting cleaned, filtered, and safe fecal material can save lives, too.

Fecal bacteria sample

(via)

Researchers at Massachusetts General Hospital have created a pill containing filtered fecal material that successfully treated 19 of 20 patients with Clostridium difficile, according to a study in the Journal of the American Medical Association. 

It’s worth repeating: this is a poop pill. And it holds the potential to save tens of thousands of lives every year. 

Though the study was quite small, it shows that fecal transplants – an extremely effective but tedious and labor-intensive procedure – can be accomplished using two or three days’ worth of simple-to-ingest pills. If larger clinical trials are successful, this will be a game-changing therapy.

Clostridium difficile, or c. diff, is a disease that is resistant to many antibiotics and kills 14,000 Americans each year. I wrote a lot about it for a Project Millennialpost last year, but the short version is that c. diff is a hospital-acquired infection that becomes problematic once a patient’s microbiome is altered – often by antibiotics that kill many types of bacteria but spare c diff.  Unconstrained by the “good” bacteria (yes, I’m simplifying here), c. diff takes over the microbiome, causing diarrhea, fever, abdominal pain, and sometimes septicemia.

Treating a c. diff exacerbation with the traditional antibiotic regime can take weeks (often in an inpatient setting) and isn’t all that effective. Fecal transplants, by contrast, lead to quick recovery and are very effective; they don’t actually wipe out c. diff, but in restoring microbiome homeostasis they “tamp it down.” And the procedure works.

More trials need to be completed to ensure that a fecal transplant in pill form is as safe and effective as early results indicate.  If the trials are successful, this therapy will be an absolute medical game-changer.

In addition to being easier to carry out, a fecal transplant in pill form will mitigate the yuck factor (even if it doesn’t entirely get rid of it). The pill fecal transplant works in a matter of days and would likely be done on an outpatient basis, which would save thousands of dollars per patient and free up hospital beds for other patients.  And finally, it bears repeating that the therapy works.

Intriguingly, this modest success opens up the possibility of pill fecal transplants for other ends, like treating depressing and losing weight. Of course, much more research needs to be done in these areas, but the prospect of probiotic therapy for various illnesses would be significant.

Isn’t science cool? Scientists and doctors have managed to turn one of Death’s surest weapons against it, if only a little.