Category: International Development

Burundi Falls Apart – Again

Bujumbura, in better days

Bujumbura, in better days

In late 2013, after a day-long bus ride through the rolling hills and lush greenery of Rwanda and northern Burundi – a trip during which one of my seatmates, evidently unaccustomed to facing her own mortality, threw up out the window – I hopped off in Bujumbura with absolutely no idea where to go next.

The Bujumbura bus park is cloistered in the back of a large, bustling market – the type of place that is wholly comfortable when familiar but bewildering and a touch intimidating when novel. My Rwandan SIM card didn’t work in Burundi and I didn’t have any Francs (or, for that matter, any French), so I wandered around until I found an exchange rate that wasn’t unreasonable and mimed a lot in order to make the exchange. SIM cards nowhere to be found and a light rain quickly turning to a downpour, I flagged a motorcycle driver, gratefully accepted his kind offer to call my friend for me, and left the park.

That bus park is likely now the site of protests against a leader, Pierre Nkurunziza, who is eschewing the constitution – if not in letter, then certainly in spirit – and running for a third term as president.

It’s now also a starting point for thousands of Burundians who are fleeing their country, to five-figure population refugee camps that didn’t exist just a few weeks ago. They’re fleeing the all-too-real chance that Bujumbura’s police force, loyal to Nkurunziza, will further turn on its citizens; that the imbonerakure, a youth paramilitary group armed with guns and nail-studded bats, will come for them and their families; that their neighbors, terrified of being thought of as “on the wrong side”, may sell them out to either group.

The prospect of a coup or a civil war has increased in the past few weeks, largely owing to military leaders who voiced support for the constitution (and therefore, the protestors).

And so Burundians are fleeing their present and their future, both inextricably tied to their recent past. A bit of history is useful here: Burundi is a landlocked country just south of Rwanda, and shares with it the bond of being previously colonized first by the Germans and then by the Belgians, as Ruanda-Urundi. The Belgians stoked (created and fomented, really) tensions between the Hutus and Tutsi, which gave way to undulating waves of ethnic violence in both countries, from their separation and independence in the early 1960s to the 1900s.

You’re certainly aware of how this played out in Rwanda: 800,000 Rwandans, mostly Tutsi, were slaughtered in 100 days over the spring and summer of 1994. The carnage subsided, and the Rwandan Patriotic Front, the rebel army that fought and beat the genocidaires, was left to rebuild the burned-out husk of a country. Over the next 20 years, spurred on by an international community flush with guilt, shame, and cash, it did just that, becoming an economic powerhouse in the region and, in the eyes of many, an exemplar for capital-G Good development in Sub-Saharan Africa.

(Obligatory caveat: Rwanda’s President Paul Kagame and his RPF deserve a great deal of criticism for the way in which they have suppressed dissent, crippled opposition, and ruled autocratically. There’s no counterfactual for how Rwanda would’ve done the past 20 years if the RPF would’ve ruled differently.)

Cibitoke, in northern Burundi. Stunningly beautiful.

Cibitoke, in northern Burundi. Stunningly beautiful.

Burundi, on the other hand, didn’t have 100 days of white-hot slaughter; it had 4,000 days of smoldering civil war. At the end of the war, with 300,000 dead, it was also left with a burned-out husk of a country, but didn’t have international guilt bankrolling its recovery; an efficient, effective autocrat forcing development at any cost; or two decades to build.

You probably knew Rwanda’s recent history; you probably didn’t know Burundi’s. The conflict in Burundi was overshadowed by Rwanda’s genocide, and, to the extent that it was news at all, the Great African Wars in the Democratic Republic of the Congo (in which Rwanda played a leading role).

Since then, of the decade Nkurunziza has been president the best thing you could say is that it could have been a lot worse. All-out war was averted and conflict stayed to a minimum.

And yet Burundi is in a really, really bad place. By whatever data source you use, Burundi is competing for the dubious honor of being the world’s poorest country; it is one of the worst places in the world for a woman to give birth; it is one of the population densest countries in Sub-Saharan Africa, with all of the land ownership issues that result; it is landlocked and has very little of value to export.

But things can get worse for the average Burundian, and quickly. In the past few weeks, the government has shut access to Facebook, WhatsApp, and other social media, and shut down the country’s main university, causing hundreds of Burundian students to seek safety at the US Embassy in Bujumbura. Demonstrators have been met with live ammunition, and the imbonerakure have harassed and murdered Burundians around the country.

This is not likely to end well, or soon. Demonstrations continue, and as the election nears, will likely be met with escalated violence. In all likelihood, things will get worse before they get better. More people will disappear or die.

Commentators have (rightly) narrowed their collective aperture to the daily demonstrations and the near-term election, but it’s worth contemplating what comes next.

In the best-case scenario, Nkurunziza wins and Burundi becomes an international pariah; aid may drop off in response, leaving the average Burundian in direr straits (indeed, this is already happening). Unfortunately, as should be obvious above, political uncertainty is just one of many challenges faced by the average Burundian; get rid of it and Burundi is still a poor, landlocked country with little of value to export and, from a tourism perspective, less to recommend it than, say, Rwanda.

In the worst-case scenario, all-out civil war, sparked by an attempted (or successful) military coup, is not inconceivable. Hundreds of thousands would flee to neighboring countries, straining the resources of those countries and aid agencies; Rwanda, worried about its stability and economic growth above all else, would intervene militarily. Economic instability, death, disease, terror, and uncertainty would follow.  What little progress was made in the past decade would vanish.

The likely outcome, of course, is somewhere in between. Nkurunziza will win, but a lot of lives will be uprooted, and lost. Burundians will be no better off than they are today. The bus park will represent desperation, hope, and hardship; one of the only ways out of an increasingly bad situation.

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:


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:


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:


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

America’s Food Aid Policy is the Worst

America’s food aid program, Food for Peace, is “by far the most inefficient and expensive food assistance delivery system in the world, and one that delays or deprives sustenance to potentially millions of people who desperately need it,” according to a Medill School of Journalism/USA Today investigation.

The entire article is worth reading (as is the whole series), but here’s the kicker:

Of the total of $17.9 billion that USAID spent in the decade from 2003 to 2012, $9.2 billion of it went toward transportation costs, including shipping, handling and storage, or 22 percent more than the $7.4 billion spent on actual food, according to the data analysis and information provided by USAID. And more than a third of the transport costs – $3.3 billion – went just for ocean freight costs. That’s more than 16 percent of the entire Food for Peace budget.

I’ve written about American food aid policy before, so won’t get too far into the weeds, but the overarching issue is that a small group of people and organizations – large farmers and American-flagged ships – are receiving a significant subsidy while everyone else – other American citizens, small farmers in low-income countries, etc. – each only pay a little.

In economics parlance, this is the “concentrated benefits, diffuse costs” problem. It leads to interest groups pressuring Congress to create and pass rent-seeking legislation, which Congress does because a) Congress; and b) Congress feels no backlash from other American citizens or the small farmers in low-income countries that are hurt by the legislation.

There’s a lot more to be said, but I want to read through all of the Medill/USA Today articles before getting to it. In the meantime, you should too.

Is Social Enterprise For Cynics?

Typical pit latrines in Mukuru Kwa Ruben, an informal settlement in Nairobi. This is what the government provides for the people

Typical pit latrines in Mukuru Kwa Ruben, an informal settlement in Nairobi. This is what the government provides for the people. Social entrepreneurs can do better.

Charles Kenny, a Senior Fellow at the Center for Global Development, is one of the sharpest minds on international development and always a delight to read. But I found his latest article, on the naiveté and cynicism of social enterprise – which he pins mainly on Millennials – a bit off the mark.

In the article, Kenny argues that social entrepreneurs are naïve, anti-institution, anti-big business cynics who are improperly substituting small-scale solutions to massive problems that require massive solutions via a large, competent central government.

Kenny is absolutely right that modern infrastructure – roads, sanitation networks, electrical grids and the like – is necessary for long-term health, development, and growth, and that small-scale solutions aren’t perfect substitutes.

But his solution, such as it is, relies on projects that require years of work carried out by competent governments, and he fails to articulate a plausible medium-term solution that will improve the lives of the people living under incompetent governments now.

Kenny creates a straw man of a social entrepreneur who expects to replace the government’s role wholesale. In my experience, this is the aim of few, if any. Social enterprise is certainly not a perfect solution and it’s not a perfect substitute for large infrastructure projects; nevertheless, it holds promise to quickly, sustainably, and successfully improve outcomes and to (temporarily) alleviate suffering.

It’s worth clarifying what a social enterprise is. The most basic definition, while overly broad, is a good place to start: any organization, for-profit or otherwise, that uses market mechanisms to achieve a social goal. That’s it. In many states, a company can legally incorporate as a “benefit corporation,” a designation meant to protect the social aim if it’s in conflict with the goal of producing profit. Many for-profits choose to also apply for “B Corps” status, a stamp of approval that designates the business as socially and environmentally “good.”

In the article, Kenny refers mostly to smaller for-profit social enterprises using innovative technologies to solve a social problem. He argues that they are naive for thinking that using markets to solve global problems would have a significant effect:

Forget bureaucracies, charities, foreign aid, and big multinationals, they might say, the best way to fight global poverty is through the right blend of innovation and business savvy. In its own way, this is simply a new brand of naiveté. The fact remains that poor countries can’t develop without a big, traditional private sector that creates jobs, and the smartest innovations can only go so far without functional governments to provide basic services and infrastructure.

Note the straw man “they might say.” Why not just ask? Extreme poverty is important to end, but so are deaths from inadequate sanitation, improper health care, and a variety of social ills.

Kenny then argues that social entrepreneurs are not just naive, but cynical too:

The social enterprise movement is built on cynicism about the public sector and large-scale private enterprise. A recent survey of 12,171 people aged 18 to 30 across 27 countries found that while 68 percent thought they had an opportunity to become entrepreneur, only 45 percent believed one person’s participation could make a difference in the current political system. For cynics who nonetheless want to change the world for the better, social enterprise offers an attractive alternative to the snail’s pace of institutional change. With a double bottom line of profit and social impact—and the right killer app—social enterprises can innovate their way to a better world.”

Emphasis mine. Let’s set aside the fact that the data point above doesn’t say anything about how cynical Millennials actually are – if anything, 45% sounds pretty high! – and that “the social enterprise movement is built on cynicism” is, well, a pretty cynical claim to make.

What’s most important is that, as Kenny recognizes, institutional changes takes a long time. It’s hard to do, and harder to do right:

Fixing the infrastructure problems and low-quality health and education services takes more, better government—even if the services are contracted out. For all the valuable work they do, social entrepreneurs can’t replace the state’s role, and they can’t function nearly as effectively where governments are poor, incompetent, or corrupt.

Kenny is absolutely correct that an effective government is needed to fix the hard and soft infrastructure problems that plague low-resource countries.

But this won’t just happen tomorrow, or next month, or next year; building functioning institutions, water pipelines, and a health care workforce can take years. Faced with the choice of being outraged about inequality or getting to work, social entrepreneurs are choosing both.

The social enterprise model isn’t borne of cynicism; it’s the logical conclusion many pragmatists come to when large infrastructure projects take decades and when traditional aid and charitably fails to sustainably improve outcomes.

To see why, take Nairobi, Kenya’s gleaming capital city and one of the most developed places in Sub-Saharan Africa. It has a population of over three million, fully half of which don’t have access to piped water or a sewage grid. The pipes and the grid will eventually be in place – the plan is to build them out by 2030 – but until then the sanitation situation is a humanitarian disaster, especially for women and children.

IMG_6609 - Copy

Sanergy’s solution for the neighborhoods and citizens the government has failed

With respect to sanitation and clean water, Nairobi’s government has failed half of its people, and traditional aid projects have been unable to do much better. Seeing these failures, a few social entrepreneurs from MIT started Sanergy, an organization that developed a toilet and a business model to sustainably improve the sanitation situation in many of the informal settlements of Nairobi. It seems to be working. (I visited Nairobi to report on Sanergy last year; you can read the resulting article at The Daily Beast)

In my experience, social entrepreneurs don’t see their organizations as perfect substitutes for strong, effective governments and institutions; they see them as sustainable, reliable stopgaps that improve the lives of people now, while governments slowly improve. This doesn’t seem cynical; it sounds pragmatic and realistic.

The argument implicit in Kenny’s piece is that social entrepreneurs should stop wasting their time outside of the system and instead work within governments – or, at least, foment outrage to effect necessary change. This is impractical – most would not be effective agents of change in, say, Uganda’s Ministry of Health – and many entrepreneurs are entrepreneurial precisely because they don’t like working within the strictures of stodgy, bureaucratic institutions. And we must not forget that in too many low-resource and infrastructure poor countries, outrage and protest are met with violence and unlawful arrest.

None of this is to argue that social enterprise is the silver bullets that will finally rid the world of extreme poverty, decrepit infrastructure, and inadequate institutions. It isn’t.

Kenny is right: ending extreme poverty and deaths because of poor infrastructure will take competent, effective governments; massive investments in infrastructure projects that are maintained and improved over time; and consistent, well-paying jobs for the growing middle class.

And to be sure, many social enterprises are either ineffective or actively harmful. Most are too small to have anything resembling the sort of effect a government infrastructure project could have, and as governments improve some social enterprises will have to step out of the way. But there’s a role for social enterprises to begin to immediately improve health and education outcomes while governments shape up and prepare to do what’s necessary to lift their citizens out of extreme poverty.

Near the end of the piece, Kenny writes, “Cynicism about government is useless. We need outrage at its performance.” There is a place for outrage, sure, but it’s taxing and often generates more heat than light. Action is better.


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.

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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.



You Should Watch/Download “Tall as the Baobab Tree” – It is Very, Very Good

I can count the number of movies shot in, or about, Sub-Saharan Africa that I genuinely like and respect on one hand. One finger, actually: The Lion King.*

tatbtNow that finger has some company: I highly recommend  Tall as the Baobab Tree. It’s easily the best movie I’ve seen in 2014 so far, and one of my top three favorites of the past three years.**

Set in a small Senegalese village, TatBT focuses on one family – a father, a mother, a son, and two daughters – that, like a starfish, is being pulled in multiple directions at once, and is trying to stay in one piece. (catch the trailer here)

The film doesn’t proselytize and isn’t a black-and-white examination of culture, tradition, and the ever-present creep of change; there aren’t good guys, bad guys, victims, and winners – just a family navigating poverty, modernity, and fate.

October: Baobab tree in Zanzibar, Tanzania

Baobab near Zanzibar’s east coast

Interestingly, the actors aren’t actors, exactly; they’re villagers, often playing the same role they do in real life. Coumba and Debo, the two young sisters and first-generation students, are actually from the village; actually sisters; and actually first-generation students. In the film, their mother was a child bride; in real life, she was too.

More than actors, they were improvisers and writers, crafting the story more to hew to reality than to a specific message. The film benefited, and it has an intimacy and a realness that would have simply been impossible otherwise.

You should definitely check it out. It may be hard/impossible to find at the theaters – I saw it at the Athena Film Festival at Barnard College – but it’s on iTunes.


*I haven’t seen that many in total, to be honest, so framing it this way is more to make a point than to be completely fair. Maybe I’m over-generalizing, but it seems that most of the movies treat the Africans as props, plot advancers, stereotypes, and pretty much everything else but characters. A short list of movies set in SSA that I haven’t seen: Hotel Rwanda, Out of Africa, The Last King of Scotland 

**The other two, as best I can remember, are A Separation and The Intouchables (both of which are also foreign films, incidentally)

Guinness Put Out a Fantastic Ad Starring the Republic of the Congo’s Sapeurs. You Should Watch It

This is a fantastic ad featuring the sapeurs of the Republic of Congo. Don’t know what that means? Just watch.

I love a lot of things about this – a friendly swag off! – but mostly I love how it shows Congo-Brazzaville’s citizens as prideful and dignified rather than war-mongering and poor and weak. Guinness released a short documentary, too, which you can – and should – watch here.

While the sapeurs are obviously uniquely concerned with appearances (and uniquely stylish as a result), it’s worth pointing out that they are aberrant only in degree. Pretty much everyone I met in East Africa – from the three-piece-suit-wearing movers and shakers in Nairobi to the rural villagers donning beautiful dresses in Cibitoke, Burundi –  highly valued looking good. You won’t see those people in the Western media, usually.

UPDATED: Fact-Checking an Article on Saving Mothers Giving Life in the Christian Science Monitor

1/22 Update: I received a response from the author, Howard LaFranchi, late last week, but haven’t had a working computer until now. He made a number of updates to the article, as he notes in his email to me (which I’m posting in full, with his blessing):

Dear Michael: Please find below a link to the corrected version of my maternal mortality story with Uganda now featured in the lede instead of Zambia.

You are indeed correct that Zambia did not implement a transport voucher program under the Saving Mothers program. My error was to conflate information I was provided on the challenges and programs in the two countries. That has now been corrected.
Your other criticisms, however, pertain to information and statistics provided by USAID, CDC, and the ministries of the two countries involved. I don’t agree with your observations, but you might want to take them up with the institutions you question.
I appreciate that a reader with your knowledge took the time to call my attention to the errors in the piece. On the other hand, I have to say that I find it a bit disheartening that someone involved in addressing the issue of maternal mortality would advocate “removal” from a general-interest site of an article that deliverers some good news on the issue.
In any case, thanks for your interest.
Best wishes, Howard

 I have a few thoughts on this, but will likely write a separate post (or update this post) later this week outlining them rather than doing so now. I very much appreciate Mr. LaFranchi allowing me to post his response.

It’s rare that I find an article (published in a prominent outlet) that is so inaccurate I feel compelled to spend some time researching and writing a rebuttal. But it happens.

This article is from the Christian Science Monitor, a great publication. Unfortunately, almost everything – the title, the statistics, and lede – is inaccurate or misleading. It needs to be modified or removed.

A bit of background: a USAID-backed partnership, Saving Mothers Giving Life (SMGL), is working to reduce maternal mortality in western Uganda and parts of Zambia, with possible scale-up districts/countries to follow. It’s a big project – $280 million over ten years (at least), with USAID, the Norwegion Ministry of Foreign Affairs, and Merck for Mothers working in tandem with the Ugandan and Zambian Ministries of Health. The partnership is implementing a number of health-systems-strengthening-related interventions that it hopes will ultimately lead to fewer maternal deaths in the area.

Let’s go through the article, paragraph by paragraph. Starting with the title (likely from the editor, not the author):

How a simple travel voucher is saving the lives of pregnant African women

This is a misleading title, for a few reasons. Even a travel voucher scheme is really complex to implement in low-resource settings like Uganda; getting the amounts right, sensitizing the community, monitoring to ensure it’s working properly – all difficult. Furthermore, the title gives the impression that SMGL is a travel voucher scheme only, when vouchers are one small piece.

While we’re on the subject, the author later notes that the project:

…has a lot more to it than rides on the motorized cycles used in those rural areas. But the availability of transportation is one key reason the program has shown impressive results in a short time, experts say

That’s quite the claim for an anonymous “experts say,” and neither the SMGL 2013 Annual Report nor the Columbia University external evaluation of SMGL analyzed specific interventions for efficacy.

Continuing, the lede:

In rural Zambia in southern Africa, a pregnant woman faces on average a five-hour walk to reach prenatal care – or a facility equipped to handle complications in birth

This could very well be true, but, like the rest of the article, there’s no linked source. I did a quick search and didn’t find any time study or survey on pregnant women in Zambia, though that obviously doesn’t mean this statement wrong – just not simple to source.

It is is a useful statistic to have; it’s visceral and emotional, and can help readers empathize with women going through pregnancy in difficult settings. But it’s useful only if it’s accurate.

Compounding the above criticism, here’s the next paragraph:

Enter a very simple idea – transport vouchers for pregnant women. Over the past year and a half of a new US-initiated program for addressing maternal mortality, Zambia began providing thousands of vouchers for women to be able to access pre-natal care and properly equipped birth facilities

This is flat-out wrong; SMGL doesn’t provide transportation vouchers as part of its program in Zambia. From the external evaluation of SMGL (p. 25):

“…over half the women (58%) who had heard of SMGL in Uganda reported familiarity with transportation vouchers compared to only 3% of women in Zambia. The contrast is unsurprising, as the SMGL program in Zambia did not provide transportation vouchers” (emphasis mine)

Sloppy journalism, plain and simple.

Here’s the next paragraph (I’ve also included a bit about Uganda from a later paragraph for clarity):

Zambia records about 2,600 maternal deaths every year, giving it a maternal mortality ratio of 440 per 100,000 live births. (In the US, the number is closer to 12 per 100,000)… [later, regarding Uganda – MM] … the maternal mortality ratio in the four districts fell from 452 to 316 per 100,000 births. Uganda’s national average is 438.”

The Zambian figure, 440 per 100,000 live births, is for 2010, and comes from the World Health Organization (WHO). For the same period and from the same source, the Maternal Mortality Ratio is 21 per 100,000 in the United States, not 12. (This is probably just a typo that was not corrected by the editor.)

Uganda’s national average is not 438, as best I can tell; according to the same source linked above from the WHO, it’s 310 per 100,000 live births in 2010. The author may have a separate source for his figure, but unless he has some reason to believe the WHO analysis is wrong for Uganda, he should be comparing apples to apples.

The author continues:

But in the maternal care facilities in the four Zambia districts participating in the Saving Mothers Giving Life (SMGL) program, the maternal mortality ratio fell by 35 percent.

This isn’t technically wrong, according to the SMGL 2013 Annual Report. But this number tells us a lot less than we would think – something that the average reader may not immediately intuit. It’s the job of a journalist to help walk the reader through statistics like this.

At the most basic level, this figure fails to tell us what would have happened in that facility were it not for SMGL; it doesn’t give a counterfactual. Maybe a similar, non-SMGL district also saw a 35% reduction in the Maternal Mortality Ratio; perhaps a similar district saw its Maternal Mortality Ratio double. We just don’t have the context, and insinuating this reduction is both good and a result of SMGL isn’t exactly appropriate.

Even if the SMGL Annual Report listed results from comparison districts, we still need to take the figure with some skepticism. SMGL wasn’t set up as a randomized controlled trial – the leadership hand-picked which districts it planned to work in – so we can’t say for sure that SMGL’s results in these districts could be expected elsewhere, nor can we say that SMGL caused the MMR to drop by 35%.

There were comparison districts in both countries for the external evaluation, but they were not random and not selected at the start of the intervention, so, in the authors’ words, “we can compare performance of SMGL versus comparison districts as of May 2013, but we cannot assess whether there was change in the SMGL districts during the year of program implementation.”

The bottom line is this: readers need more information before they can understand what “fell by 35%” actually means, and it’s a journalists job to find that information and walk them through it.

Finally, after a quote from Dr. Rajiv Shah, the administrator for USAID, the article continues:

The Saving Mothers initial program cost $20 million – or about $7 per birth under the program in Zambia, and about $13 per birth in Uganda.

This is going to get wonky, so I won’t bury the lede: the above figures make no sense to me, and I have no idea where they came from. To start, $20 million is the cost of the pilot program for both Uganda ($10,505,255), and Zambia ($8,144,510), some of which was long-term capital investment (e.g., equipment, construction) and some of which was short-term/admin expense (e.g., salaries, transportation vouchers) over a 17- and 20-month period, respectively.

Let’s look at figures for Uganda:

  • According to the SMGL 2013 Annual Report, $10,505,255 was allocated to Uganda, of which 29% was for capital expenditures which were expected to last for five years. So, taking .71*$spent+ (.20*capex) should give us a very conservative figure (i.e., erring low) to start with: $8,068,036 ($7,458,731 + .2*(.29*10,505,255))). At $13 per birth, there would be 620,619 births, according to the statistics the CSM author reports
  • Quick gut check: is 620,619 births reasonable? The same report lists Uganda as having 1.5 million births per year, or about 2.125 million every 17 months (the time period listed for the disbursement in Uganda). Does it make sense to have 29% of the country’s births come from four western districts (Uganda has 111 districts total)? Probably not
  • Furthermore, the external evaluation lists  78,400 “deliveries, annual” in the four Uganda districts in 2011. Correcting for number of months and assuming this only is facility deliveries (to err on the side of caution), the estimated total number of births in the four districts during the period would be about 198,333 – less than one third the figure I got by reverse-engineering the author’s data.

I could do the same with the Zambian figures, but it’s beside the point. The author should back up his assertion with data and sources; right now, it’s as if these figures were just pulled from the ether.

But. Let’s assume, for the sake of argument, that the author’s figures hold up. What do they tell us? With the right additional information, it’s possible we could use them to best prioritize the next marginal dollar of investment; it would be better, one could argue, to invest that dollar in an area with a high birth rate than an one with a low birth rate, all else equal.

Or maybe not. Why not ask if its possible to invest in family planning services that will drive down the number of births in an area? That wouldn’t be captured in this metric (it would actually make the cost per birth higher), but it could be a valuable way to reduce the number of maternal and child deaths.

All of which is to say: this metric doesn’t tell us anything meaningful.

The author then spends the remainder of the article discussing maternal mortality more generally.

The point of this isn’t to castigate one specific writer, or even one specific publication – it’s to highlight the need for quality journalism on global health/development topics. If it’s worth writing about (and it is!) it’s worth writing about well.

I’ve emailed the author and will post a response if I receive one.


A Masterclass in How to Do Appropriate “African” Advertising

This video, made for a project of Dutch NGO SYPO, Microbanker*, is fantastic, well-done, and proof positive that compelling NGO advertising about “Africans” can be empowering to the community rather than merely reductive pieces of poverty/ruin porn:

It’s now my second-favorite NGO advertisement for “Africa,” after the one about the little Kenyan boy working on his bucket list.

(Hat tip to Jina Moore – a great independent journalist)

*I haven’t heard anything about the NGO’s programs other than what I read at the website, so don’t view this as an endorsement of their work – just of their advertising philosophy and acumen. It looks like they do something vaguely Kiva-ish in Mukono District