Ebola and health workers

It starts with familiar flu-like symptoms: a mild fever, headache, muscle and joint pains. But within days this can quickly descend into something more exotic and frightening: vomiting and diarrhoea, followed by bleeding from the gums, the nose and gastrointestinal tract.

Death comes in the form of either organ failure or low blood pressure caused by the extreme loss of fluids.

Such fear-inducing descriptions have been doing the rounds in the media lately.

However, this is not Ebola but rather Dengue Shock Syndrome, an extreme form of dengue fever, a mosquito-borne disease that struggles to make the news.

That's Seth Berkley, CEO of the GAVI Alliance, writing an opinion piece for the BBC. Berkley argues that Ebola grabs headlines not because it is particularly infectious or deadly, but because those of us from wealthy countries have otherwise forgotten what it's like to be confronted with a disease we do not know how to or cannot afford to treat.

However, in wealthy countries, thanks to the availability of modern medicines, many of these diseases can now usually be treated or cured, and thanks to vaccines they rarely have to be. Because of this blessing we have simply forgotten what it is like to live under threat of such infectious and deadly diseases, and forgotten what it means to fear them.

Ebola does combine infectiousness and rapid lethality, even with treatment, in a way that few diseases do, and it's been uniquely exoticized by books like the Hot Zone. But as Berkley and many others have pointed out, the fear isn't really justified in wealthy countries. They have health systems that can effectively contain Ebola cases if they arrive -- which I'd guess is more likely than not. So please ignore the sensationalism on CNN and elsewhere. (See for example Tara Smith on other cases when hemorraghic fevers were imported into the US and contained.)

But one way that Ebola is different -- in degree if not in kind -- to the other diseases Berkley cites (dengue, measles, childhood diseases) is that its outbreaks are both symptomatic of weak health systems and then extremely destructive to the fragile health systems that were least able to cope with it in the first place.

Like the proverbial canary in the coal mine, an Ebola outbreak reveals underlying weaknesses in health systems. Shelby Grossman highlights this article from Africa Confidential:

MSF set up an emergency clinic in Kailahun [Sierra Leone] in June but several nurses had already died in Kenema. By early July, over a dozen health workers, nurses and drivers in Kenema had contracted Ebola and five nurses had died. They had not been properly equipped with biohazard gear of whole-body suit, a hood with an opening for the eyes, safety goggles, a breathing mask over the mouth and nose, nitrile gloves and rubber boots.

On 21 July, the remaining nurses went on strike. They had been working twelve-hour days, in biohazard suits at high temperatures in a hospital mostly without air conditioning. The government had promised them an extra US$30 a week in danger money but despite complaints, no payment was made. Worse yet, on 17 June, the inexperienced Health and Sanitation Minister, Miatta Kargbo, told Parliament that some of the nurses who had died in Kenema had contracted Ebola through promiscuous sexual activity.

Only one nurse showed up for work on 22 July, we hear, with more than 30 Ebola patients in the hospital. Visitors to the ward reported finding a mess of vomit, splattered blood and urine. Two days later, Khan, who was leading the Ebola fight at the hospital and now with very few nurses, tested positive. The 43-year-old was credited with treating more than 100 patients. He died in Kailahun at the MSF clinic on 29 July...

In addition to the tragic loss of life, there's also the matter of distrust of health facilities that will last long after the epidemic is contained. Here's Adam Nossiter, writing for the NYT on the state of that same hospital in Kenema as of two days ago:

The surviving hospital workers feel the stigma of the hospital acutely.

“Unfortunately, people are not coming, because they are afraid,” said Halimatu Vangahun, the head matron at the hospital and a survivor of the deadly wave that decimated her nursing staff. She knew, all throughout the preceding months, that one of her nurses had died whenever a crowd gathered around her office in the mornings.

There's much to read on the current outbreak -- see also this article by Denise Grady and Sheri Fink (one of my favorite authors) on tracing the index patient (first case) back to a child who died in December 2013. One of the saddest things I've read about previous Ebola outbreaks is this profile of Dr. Matthew Lukwiya, a physician who died fighting Ebola in Uganda.

The current outbreak is different in terms of scale and its having reached urban areas, but if you read through these brief descriptions of past Ebola outbreaks (via Wikipedia) you'll quickly see that the transmission to health workers at hospitals is far too typical. Early transmission seems to be amplified by health facilities that weren't properly equipped to handle the disease. (See also this article article (PDF) on a 1976 outbreak.) The community and the brave health workers responding to the epidemic then pay the price.

Ebola's toll on health workers is particularly harsh given that the affected countries are starting with an incredible deficit. I was recently looking up WHO statistics on health worker density, and it struck me that the three countries at the center of the current Ebola outbreak are all close to the very bottom of rankings by health worker density. Here's the most recent figures for the ratio of physicians and nurses to the population of each country:* 

Liberia has already lost three physicians to Ebola, which is especially tragic given that there are so few Liberian physicians to begin with: somewhere around 60 (in 2008). The equivalent health systems impact in the United States would be something like losing 40,000 physicians in a single outbreak.

After the initial emergency response subsides -- which will now be on an unprecedented scale and for an unprecedented length of time -- I hope donors will make the massive investments in health worker training and systems strengthening that these countries needed prior to the epidemic. More and better trained and equipped health workers will save lives otherwise lost to all the other infectious diseases Berkley mentioned in the article linked above, but they will also stave off future outbreaks of Ebola or new diseases yet unknown. And greater investments in health systems years ago would have been a much less costly way -- in terms of money and lives -- to limit the damage of the current outbreak.  

(*Note on data: this is quick-and-dirty, just to illustrate the scale of the problem. Ie, ideally you'd use more recent data, compare health worker numbers with population numbers from the same year, and note data quality issues surrounding counts of health workers)

(Disclaimer: I've remotely supported some of CHAI's work on health systems in Liberia, but these are my personal views.)

A more useful aid debate

Ken Opalo highlights recent entries on the great aid debate from Bill Gates, Jeff Sachs, Bill Easterly, and Chris Blattman. Much has been said on this debate, and sometimes it feels like it's hard to add anything new. But since having a monosyllabic first name seem sufficient qualification to weigh in, I will. First, this part of Ken's post resonates with me:

I think most reasonable people would agree that Sachs kind of oversold his big push idea in The End of Poverty. Or may be this was just a result of his attempt to shock the donor world into reaching the 0.7 percent mark in contributions. In any event it is unfortunate that the debate on the relative efficacy of aid left the pages of journal articles in its current form. It would have been more helpful if the debate spilled into the public in a policy-relevant form, with questions like: under what conditions does aid make a difference? What can we do to increase the efficacy of aid? What kinds of aid should we continue and what kinds should we abolish all together? (emphasis added)

Lee Crawfurd wrote something along these lines too: "Does Policy Work?"  Lee wrote that on Jan 10, 2013, and I jokingly said it was the best aid blog post of the year (so far). Now that 2013 has wrapped up, I'll extend that evaluation to 'best aid blog post of 2013'. It's worth sharing again:

The question "does policy work" is jarring, because we immediately realise that it makes little sense. Governments have about 20-30 different Ministries, which immediately implies at least 20-30 different areas of policy. Does which one work? We have health and education policy, infrastructure policy (roads, water, energy), trade policy, monetary policy, public financial management, employment policy, disaster response, financial sector policy, climate and environment policy, to name just a few. It makes very little sense to ask if they all collectively "work" or are "effective". Foreign aid is similar. Aid supports all of these different areas of policy....

A common concern is about the impact of aid on growth... Some aid is specifically targeted at growth - such as financing infrastructure or private sector development. But much of it is not. One of the few papers which looks at the macroeconomic impact of aid and actually bothers to disaggregate even a little the different types of aid, finds that the aid that could be considered to have growth as a target, does increase growth. It's the aid that was never intended to impact growth at all, such as humanitarian assistance, which doesn't have any impact on growth.

I like to think that most smart folks working on these issues -- and that includes both Sachs and Easterly -- would agree with the following summaries of our collective state of knowledge:

  •  A lot of aid projects don't work, and some of them do harm.
  • Some aid, especially certain types of health projects, works extremely well.

The disagreement is on the balance of good and bad, so I wish -- as Ken wrote -- the debate spilled into the public sphere along those lines (which is good? which is bad? how can we get a better mix?) rather than the blanket statements both sides are driven to by the very publicness of the debate. It reminds me a bit of debates in theology: if you put a fundamentalist and Einstein in the same room, they'll both be talking about "God" but meaning very different things with the same words. (This is not a direct analogy, so don't ask who is who...)

When Sachs and Easterly talk about whether aid "works", it would be nice if we could get everyone to first agree on a definition of "aid" and "works". But much of this seems to be driven by personal animosity between Easterly and Sachs, or more broadly, by personal animosity of a lot of aid experts vs. Sachs. Why's that? I think part of the answer is that it's hard to tell when Sachs is trying to be a scientist, and when he's trying to be an advocate. He benefits from being perceived as the former, but in reality is much more the latter. Nina Munk's The Idealist -- an excellent profile of Sachs I've been meaning to review -- explores this tension at some length. The more scientifically-minded get riled up by this confusion -- rightfully, I think. At the same time, public health folks tend to love Sachs precisely because he's been a powerful advocate for some types of health aid that demonstrably work -- also rightfully, I think. There's a tension there, and it's hard to completely dismiss one side as wrong, because the world is complicated and there are many overlapping debates and conversations; academic and lay, public and private, science and advocacy.

So, back to Ken's questions that would be answered by a more useful aid debate:

  • Under what conditions does aid make a difference?
  • What can we do to increase the efficacy of aid?
  • What kinds of aid should we continue and what kinds should we abolish all together?

Wouldn't it be amazing if the public debate were focused on these questions? Actually, something like that was done: Boston Review had a forum a while back on "Making Aid Work" with responses by Abhijit Banerjee, Angus Deaton, Howard White, Ruth Levine, and others. I think that series of questions is much more informative than another un-moderated round of Sachs vs Easterly.

Rearranging the malarial deck chairs?

A friend sent this link to me, highlighting a critical comment about the future of the World Health Organization, in the context of the World Malaria Report 2012. Here's an excerpt of the comment by William Jobin:

Their 2012 Annual Report is a very disturbing report from WHO, for at least two reasons:

1. Their program is gradually falling apart, and they offer no way to refocus, no strategy for dealing with the loss in funding, nor the brick wall of drug and biocide resistance which is just down the road. There is a label for people who keep doing the same thing, but expect different results. Do you remember what it is?

2. Because the entire top management of WHO consists of physicians, they have no idea of the opportunities they are missing for additional funding and for additional methods to add to their chemically-oriented strategy...

Concluding with:

I am not sure WHO has much of a future, nor does the UN system itself, after their failure to prevent the wars in Libya and Syria. But as long as the UN and WHO continue to operate, they must refocus their approach to face the reality of a rapidly declining budget from UN sources. Instead, I see them just re-arranging the deck chairs on the Titanic.

My friend said, "I wish these comments (and issues with the WHO and UN) were more publicised! This is not the first time I am hearing of such issues with the WHO and its demise." I've certainly heard similar sentiments about the WHO from classmates and professors, but it seems there's much less open discussion than you might expect. I'd welcome discussion in the comments...

"As it had to fail"

My favorite line from the Anti-Politics Machine is a throwaway. The author, James Ferguson, an anthropologist, describes a World Bank agricultural development program in Lesotho, and also -- through that lens -- ends up describing development programs more generally. At one point he notes that the program failed "as it had to fail" -- not really due to bad intentions, or to lack of technical expertise, or lack of funds -- but because failure was written into the program from the beginning. Depressing? Yes, but valuable. I read in part because Chris Blattman keeps plugging it, and then shortly before leaving for Ethiopia I saw that a friend had a copy I could borrow. Somehow it didn't make it onto reading lists for any of my classes for either of my degrees, though it should be required for pretty much anyone wanting to work in another culture (or, for that matter, trying to foment change in your own). Here's Blattman's description:

People’s main assets [in Lesotho] — cattle — were dying in downturns for lack of a market to sell them on. Households on hard times couldn’t turn their cattle into cash for school fees and food. Unfortunately, the cure turned out to be worse than the disease.

It turns out that cattle were attractive investments precisely because they were hard to liquidate. With most men working away from home in South Africa, buying cattle was the best way to keep the family saving rather than spending. They were a means for men to wield power over their families from afar.

Ferguson’s point was that development organizations attempt to be apolitical at their own risk. What’s more, he argued that they are structured to remain ignorant of the historical, political and cultural context in which they operate.

And here's a brief note from Foreign Affairs:

 The book comes to two main conclusions. First is that the distinctive discourse and conceptual apparatus of development experts, although good for keeping development agencies in business, screen out and ignore most of the political and historical facts that actually explain Third World poverty-since these realities suggest that little can be accomplished by apolitical "development" interventions. Second, although enormous schemes like Thaba-Tseka generally fail to achieve their planned goals, they do have the major unplanned effect of strengthening and expanding the power of politically self-serving state bureaucracies. Particularly good is the discussion of the "bovine mystique," in which the author contrasts development experts' misinterpretation of "traditional" attitudes toward uneconomic livestock with the complex calculus of gender, cash and power in the rural Lesotho family.

The reality was that Lesotho was not really an idyllically-rural-but-poor agricultural economy, but rather a labor reserve more or less set up by and controlled by apartheid South Africa. The gulf between the actual political situation and the situation as envisioned by the World Bank -- where the main problems were lack of markets and technical solutions -- at the time was enormous. This lets Ferguson have a lot of fun showing the absurdities of Bank reports from the era, and once you realize what's going on it's quite frustrating to read how the programs turned out, and to wonder how no one saw it coming.

This contrast between rhetoric and reality is the book's greatest strength: because the situation is absurd, it illustrates Ferguson's points very well, that aid is inherently political, and that projects that ignore that reality have their future failure baked in from the start. But that contrast is a weakness too, as because the situation is extreme you're left wondering just how representative the case of Lesotho really was (or is). The 1970s-80s era World Bank certainly makes a great buffoon (if not quite a villain) in the story, and one wonders if things aren't at least a bit better today.

Either way, this is one of the best books on development I've read, as I find myself mentally referring to it on a regular basis. Is the rhetoric I'm reading (or writing) really how it is? Is that technical, apolitical sounding intervention really going to work? It's made me think more critically about the role outside groups -- even seemingly benevolent, apolitical ones -- have on local politics. On the other hand, the Anti-Politics Machine does read a bit like it was adapted from an anthropology dissertation (it was); I wish it could get a new edition with more editing to make it more presentable. And a less ugly cover. But that's no excuse -- if you want to work in development or international health or any related field, it should be high on your reading list.

Sentimental narratives

In his contribution to the book Humanitarianism and Suffering, historian Thomas Laqueur charts the birth of “the sentimental narrative” and its role in changing hearts and inspiring action. “In the late eighteenth century,” he writes, “the ethical subject was democratized; more and more people came to believe it was their obligation to ameliorate and prevent wrongdoing to others.” The sentimental narrative Lacquer identifies is a sneaky one. Superficially, it seems humane, a good-hearted response to the impoverished and their plight. But it also objectifies the sufferers it nominally empowers—people with pain to ameliorate, against whom wrongdoings are to be prevented, on whose behalf this compassion is to be invested. However many noble or real or useful things that investment may bring, it also flatters us, by affirming our own righteousness.

That's from Jina Moore's essay in the Boston Review on telling stories about Africa as a foreigner. It's definitely worth a read, as is her follow-up blog post, "Good News from Africa," (in the sense that the news is well-done, not that the news is always "good") which highlights several examples of the extraordinary writing she'd like to see more of. And follow @itsjina on Twitter.

Aid, paternalism, and skepticism

Bill Easterly, the ex-blogger who just can't stop, writes about a conversation he had with GiveWell, a charity reviewer/giving guide that relies heavily on rigorous evidence to pick programs to invest in. I've been meaning to write about GiveWell's approach -- which I generally think is excellent. Easterly, of course, is an aid skeptic in general and a critic of planned, technocratic solutions in particular. Here's an excerpt from his notes on his conversation with GiveWell:

...a lot of things that people think will benefit poor people (such as improved cookstoves to reduce indoor smoke, deworming drugs, bed nets and water purification tablets) {are things} that poor people are unwilling to buy for even a few pennies. The philanthropy community’s answer to this is “we have to give them away for free because otherwise the take-up rates will drop.” The philosophy behind this is that poor people are irrational. That could be the right answer, but I think that we should do more research on the topic. Another explanation is that the people do know what they’re doing and that they rationally do not want what aid givers are offering. This is a message that people in the aid world are not getting.

Later, in the full transcript, he adds this:

We should try harder to figure out why people don’t buy health goods, instead of jumping to the conclusion that they are irrational.

Also:

It's easy to catch people doing irrational things. But it's remarkable how fast and unconsciously people get things right, solving really complex problems at lightning speed.

I'm with Easterly, up to a point: aid and development institutions need much better feedback loops, but are unlikely to develop them for reasons rooted in their nature and funding. The examples of bad aid he cites are often horrendous. But I think this critique is limited, especially on health, where the RCTs and all other sorts of evidence really do show that we can have massive impact -- reducing suffering and death on an epic scale -- with known interventions. [Also, a caution: the notes above are just notes and may have been worded differently if they were a polished, final product -- but I think they're still revealing.]

Elsewhere Easterly has been more positive about the likelihood of benefits from health aid/programs in particular, so I find it quite curious that his examples above of things that poor people don't always price rationally are all health-related. Instead, in the excerpts above he falls back on that great foundational argument of economists: if people are rational, why have all this top-down institutional interference? Well, I couldn't help contrasting that argument with this quote highlighted by another economist, Tyler Cowen, at Marginal Revolution:

Just half of those given a prescription to prevent heart disease actually adhere to refilling their medications, researchers find in the Journal of American Medicine. That lack of compliance, they estimate, results in 113,00 deaths annually.

Let that sink in for a moment. Residents of a wealthy country, the United States, do something very, very stupid. All of the RCTs show that taking these medicines will make them live longer, but people fail to overcome the barriers at hand to take something that is proven to make them live longer. As a consequence they die by the hundreds of thousands every single year. Humans may make remarkably fast unconscious decisions correctly in some spheres, sure, but it's hard to look at this result and see any way in which it makes much sense.

Now think about inserting Easterly's argument against paternalism (he doesn't specifically call it that here, but has done so elsewhere) in philanthropy here: if people in the US really want to live, why don't they take these medicines? Who are we to say they're irrational? That's one answer, but maybe we don't understand their preferences and should avoid top-down solutions until we have more research.

A reductio ad absurdum? Maybe. On the one hand, we do need more research on many things, including medication up-take in high- and low-income countries. On the other hand, aid skepticism that goes far enough to be against proven health interventions just because people don't always value those interventions rationally seems to line up a good deal with the sort of anti-paternalism-above-all streak in conservatism that opposes government intervention in pretty much every area. Maybe it's a good policy to try out some nudge-y (libertarian paternalism, if you will) policies to encourage people to take their medicine, or require people to have health insurance they would not choose to buy on their own.

Do you want to live longer? I bet you do, and it's safe to assume that people in low-income countries do as well. Do you always do exactly what will help you do so? Of course not: observe the obesity pandemic. Do poor people really want to suffer from worms or have their children die from diarrhea? Again, of course not. While poor people in low-income countries aren't always willing to invest a lot of time or pay a lot of money for things that would clearly help them stay alive for longer, that shouldn't be surprising to us. Why? Because the exact same thing is true of rich people in wealthy countries.

People everywhere -- rich and poor -- make dumb decisions all the time, often because those decisions are easier in the moment due to our many irrational cognitive and behavioral tics. Those seemingly dumb decisions usually reveal the non-optimal decision-making environments in which we live, but you still think we could overcome those things to choose interventions that are very clearly beneficial. But we don't always. The result is that sometimes people in low-income countries might not pay out of pocket for deworming medicine or bednets, and sometimes people in high-income countries don't take their medicine -- these are different sides of the same coin.

Now, to a more general discussion of aid skepticism: I agree with Easterly (in the same post) that aid skeptics are a "feature of the system" that ultimately make it more robust. But it's an iterative process that is often frustrating in the moment for those who are implementing or advocating for specific programs (in my case, health) because we see the skeptics as going too far. I'm probably one of the more skeptical implementers out there -- I think the majority of aid programs probably do more harm than good, and chose to work in health in part because I think that is less true in this sector than in others. I like to think that I apply just the right dose of skepticism to aid skepticism itself, wringing out a bit of cynicism to leave the practical core.

I also think that there are clear wins, supported by the evidence, especially in health, and thus that Easterly goes too far here. Why does he? Because his aid skepticism isn't simply pragmatic, but also rooted in an ideological opposition to all top-down programs. That's a nice way to put it, one that I think he might even agree with. But ultimately that leads to a place where you end up lumping things together that are not the same, and I'll argue that that does some harm. Here are two examples of aid, both more or less from Easterly's post:

  • Giving away medicines or bednets free, because otherwise people don't choose to invest in them; and,
  • A World Bank project in Uganda that "ended up burning down farmers’ homes and crops and driving the farmers off the land."

These are a both, in one sense, paternalistic, top-down programs, because they are based on the assumption that sometimes people don't choose to do what is best for themselves. But are they the same otherwise? I'd argue no. One might argue that they come from the same place, and an institution that funds the first will inevitably mess up and do the latter -- but I don't buy that strong form of aid skepticism. And being able to lump the apparently good program and the obviously bad together is what makes Easterly's rhetorical stance powerful.

If you so desire, you could label these two approaches as weak coercion and strong coercion. They are both coercive in the sense that they reshape the situations in which people live to help achieve an outcome that someone -- a planner, if you will -- has decided is better. All philanthropy and much public policy is coercive in this sense, and those who are ideologically opposed to it have a hard time seeing the difference. But to many of us, it's really only the latter, obvious harm that we dislike, whereas free medicines don't seem all that bad. I think that's why aid skeptics like Easterly group these two together, because they know we'll be repulsed by the strong form. But when they argue that all these policies are ultimately the same because they ignore people's preferences (as demonstrated by their willingness to pay for health goods, for example), the argument doesn't sit right with a broader audience. And then ultimately it gets ignored, because these things only really look the same if you look at them through certain ideological lenses.

That's why I wish Easterly would take a more pragmatic approach to aid skepticism; such a form might harp on the truly coercive aspects without lumping them in with the mildly paternalistic. Condemning the truly bad things is very necessary, and folks "on the inside' of the aid-industrial complex aren't generally well-positioned to make those arguments publicly. However, I think people sometimes need a bit of the latter policies, the mildly paternalistic ones like giving away medicines and nudging people's behavior -- in high- and low-income countries alike. Why? Because we're generally the same everywhere, doing what's easiest in a given situation rather than what we might choose were the circumstances different. Having skeptics on the outside where they can rail against wrongs is incredibly important, but they must also be careful to yell at the right things lest they be ignored altogether by those who don't share their ideological priors.

Where are the programs?

An excerpt from Bill Gates' interview with Katherine Boo, author of Behind the Beautiful Forevers (about a slum in Mumbai):

Bill Gates: Your peek into the operations of some non-profits was concerning. Are there non-profits that have been doing work which actually contributes to the improvement of these environments? Katherine Boo: There are many nonprofits doing work that betters lives and prospects in India, from SEWA to Deworm the World, but in the airport slums, the closer I looked at NGOs, the more disheartened I felt. WorldVision, the prominent Christian charity, had made major improvements to sanitation some years back, but mismanagement and petty corruption in the organization's local office had hampered more recent efforts to distribute aid. Other NGOs were supposedly running infant-health programs and schools for child laborers, but that desperately needed aid existed only on paper. Microfinance groups were reconfigured to exploit the very poor. Annawadi residents dying of untreated TB, malaria and dengue fever were nominally served by many charitable organizations, but in reality encountered only a single strain of health advocate—from the polio mop-up campaign. (To Annawadians, the constant appearance of polio teams in slum lanes being eviscerated by other illnesses has  become a local joke.) I tend to be realistic about occasional failures and "leakages" in organizations that do ambitious work in difficult contexts, but the discrepancy between what many NGOs were claiming in fundraising materials and what they were actually doing was significant.

In general, I suspect that the reading public overestimates the penetration of effective NGOs in low-income communities--a misapprehension that we journalists help create. When writing about nonprofits, we tend to focus either on scandals or on thinly reported "success stories" that, en masse, create the impression that most of the world's poor are being guided through life by nigh-heroic charitable assistance. It'd be cool to see that misperception become more of a reality in the lives of low-income families.

The ABBAs

Aid blogger Tom Murphy is hosting the (third?) annual Aid Blogger's Best Awards (ABBAs). My series of posts on "Machine Gun Preacher" Sam Childers is up for the "Best Series" ABBA. If you missed my writing on Mr Childers the first time around there's a shorter version at Foreign Policy, a longer version here, and the latest updates on the whole sad story here.

Vote for that and the other awards at Tom's blog, a View From the Cave.

The Ghost of 0.7%

One thing about being new to a field is that you not only have to keep up with the latest developments, but also have to explore the voluminous literature that built up before your time. A lot of it is no longer relevant, but there's a lot of good stuff that isn't appearing on social media or in the news. Case in point: this working paper by Michael Clemens and Todd Moss of CGD, "Ghost of 0.7%: Origins and Relevance of the International Aid Target" (PDF). The abstract:

The international goal for rich countries to devote 0.7% of their national income to development assistance has become a cause célèbre for aid activists and has been accepted in many official quarters as the legitimate target for aid budgets. The origins of the target, however, raise serious questions about its relevance.

First, the 0.7% target was calculated using a series of assumptions that are no longer true, and justified by a model that is no longer considered credible. When we use essentially the same method used to arrive at 0.7% in the early 1960s and apply today’s conditions, it yields an aid goal of just 0.01% of rich-country GDP for the poorest countries and negative aid flows to the developing world as a whole. We do not claim in any way that this is the ‘right’ amount of aid, but only that this exercise lays bare the folly of the initial method and the subsequent unreflective commitment to the 0.7% aid goal.

Second, we document the fact that, despite frequent misinterpretation of UN documents, no government ever agreed in a UN forum to actually reach 0.7%—though many pledged to move toward it.

Third, we argue that aid as a fraction of rich country income does not constitute a meaningful metric for the adequacy of aid flows. It would be far better to estimate aid needs by starting on the recipient side with a meaningful model of how aid affects development. Although aid certainly has positive impacts in many circumstances, our quantitative understanding of this relationship is too poor to accurately conduct such a tally. The 0.7% target began life as a lobbying tool, and stretching it to become a functional target for real aid budgets across all donors is to exalt it beyond reason. That no longer makes any sense, if it ever did.

What if you start from an estimate of recipient 'need' rather than from the donor end?

One recent estimate that does try to start from the recipient ‘need’ and add up the costs is the Millennium Project.69 Even if one were to accept their methodology and their long list of recommended interventions (many of which are problematic), they nonetheless only arrive at 0.54% of rich country GNI as the total aid requirement. That is, even the most ambitious estimates suggest that 0.7% is vastly overstated.

But from a purely political point of view, aren't these goals helpful? (As they ask it, "Is there any harm in promoting nonsensical goals?") Their answer to this is more cursory, but basically they hypothesize that the 0.7% goal may be politically useful in European countries, while it may be counterproductive in the United States where it represents a drastic -- and politically unlikely -- increase in aid.

US global health architecture

How confusing is the US global health bureaucracy? Here's a sentence with 6 acronyms to help clear it up:

We tried to map out what the USG GH architecture might look like with USAID as the GHI leader, and OGAC as the PEPFAR coordinator; after several attempts to create a diagram, we gave up.

From "Is USAID Being Set Up to Fail on the GHI?" by Nandini Oomman and Rachel Silverman.

How Sam Childers endangers humanitarians everywhere - reax from the web

(For background see my original long post and this update.) Sam Childers gets back from Somalia (where he's currently scouting for a humanitarian mission??) on August 10th, and I've been asked to contact him. I plan to, as I want to see if he's willing to answer some of the many questions that potential donors deserve answers to -- based on his own prior statements.

In the mean time, several aid/development bloggers have written about the Machine Gun Preacher:

A couple short mentions: Tom Murphy and Ken Opalo both link, while Tom Paulson at Humanosphere calls it all "fascinating and disturbing."

Tales from the Hood is a long-running blog written by "J." While the author is anonymous, many aid / development bloggers have met him (including me) or know who he is and what he does -- which is how we know that he's not just talk: he's a legit humanitarian bad-ass who's worked in countries your high school geography teacher has never heard of. J's work is widely respected and his blog is a watering hole for aid and development workers around the globe. He also has a certain flair for description, as you can see in his piece on Childers:

[Childers] has a custom chopper and a movie deal, and when he’s not out busting caps into LRA, Childers pastors a biker-themed church in rural Pennsylvania (but of course). I think my favorite part is where he states that he is after Joseph Kony. Like, to kill him. Like, good old-fashioned cowboys and Africans.

And nothing says, “I worship the Prince of Peace” quite like vowing to kill someone.

While some commenters on this blog have said that Childers' actions are just "between him and God" -- and thus we shouldn't criticize him -- in reality nobody works in a vacuum. Reckless actions today can make future work via more reasonable approaches impossible. This critique, regarding how what Childers does and says can impact humanitarians everywhere, is very important. Here's J again:

There is already suspicion, in some cases rightly earned, that humanitarian aid workers may not be strictly humanitarian... But thanks to the Machine Gun Preacher, next time I'm stopped and questioned at a checkpoint, it will be even harder for me to make the case that I'm really there (wherever 'there' is) for strictly humanitarian purposes. And so that we're clear, this is true regardless of whether I'm in Killinochi, Erbil, or LAX. His videos and pics (along with those of many others) are up there, out in the open for all to see...

I have colleagues and close personal friends in South Sudan, including exactly the areas where Sam Childers claims to “help where no one else will.” I frequently must make the decision to deploy people who I supervise and for whom I am responsible to places where the ratio of assault rifles to healthy babies in the general population is far higher than it should be.... We very often go into insecure places where our presence and the associated suspicion that we may have ulterior motives puts not only us, but our local colleagues and those we’re trying to help at greater risk, too.

And so every time the inarticulate Machine Gun Preacher packs heat into South Sudan he makes the entire world more dangerous for me and my friends and innumerable real aid worker colleagues. Every time he puts up another video of himself jumping into his white SUV with an AK47 across his lap, he increases the likelihood that I or someone I care about is going to get shot.

Commenter MB adds this:

As someone who spent many years in South Sudan (pre- and post- CPA), who is currently in Iraq (stuck behind T-walls and armored SUVs)… this burns me up!. Any one who portrays us as CIA, military, armed, mercenary, or anything other than trying to help is beyond stupid! And anyone who would do a “reality series” (is that for real??) about them puts all of our lives, the lives of our friend, colleagues and those we are trying to help, in serious danger!...

Later in the thread the same commenter notes:

I think it’s fairly telling that those of us who have worked in South Sudan, over many years and people currently in South Sudan (a friend did an informal poll of people she knows there) knew nothing whatsoever about this guy.

I've heard the same sentiment from others, which is telling. I've also exchanged emails with two people in Sudan who have raised other concerns about Sam, and I'm hoping that they'll decide to share those publicly soon. While there are some supporters who will believe Childers is on a mission from God regardless of what I say (or anyone else for that matter), it's important for anyone who has information or concerns about Childers to share them as the publicity machine for the movie gears up. On that note, it would be great if someone who edits Wikipedia (I won't because I think I'm too close to the issue) could update his ridiculously one-sided Wikipedia page to have a more objective voice.

Another aid worker who blogs, Erin in Juba, adds some thoughts here. She notes this passage from the Machine Gun Preacher blog:

As we neared Nimule we began to relax but we weren’t out of danger yet.  We rounded a corner and hurtled in a tribal clash between the Dinka and Madi tribes.  4,000 fighters, armed with pangas (machetes), rudimentary bows, spears and clubs, stormed back and forth looking for someone to fight.  In amongst the drunks I saw an elderly man poised for battle and a young woman with a bow in her hand and a baby slung across her back.  As the situation escalated we had no choice but to lock and load.  Shots were fired and we drove through the screaming remnants of the volatile mob.  Luckily, no one was killed.

If that strikes you as outlandish, you may appreciate Erin's take:

AGGGGHHHHHH.  Tribal violence in South Sudan is a complicated clusterf[***], to say the least. However, most of the violence is in between the tribes. The traditions of violence and cattle raiding go back generations, and are a tragedy for sure, but because of their specific tribal-focused aims, they tend to not focus on targeting humanitarians.  And then this idiot claims he has “no choice” but to go blazing into the middle of a mob? ...

Right. She also notes:

It’s also ironic that Sam claims to work with the SPLA to free child soldiers since the army had its very own child soldier branch (the Red Army).

For now the feedback is this: some aid workers who work in Sudan and other dangerous environments think Childers' stories should be taken with a grain of salt, and say that what he is doing makes this work more dangerous for everyone. All of the supporting statements seem to be coming from people who are associated with his church and don't seem to question Rev. Childers at all. They shouldn't expect the same free pass as the movie brings him more attention. Childers has simply said a lot of outrageous things, and if he wants people to trust his judgment and give him money he has his work cut out for him.

Another way to help in Somalia

One of the best ways to address the severe acute malnutrition seen during famines -- like the one in Somalia now -- is a Ready-to-Use Therapeutic Food (RUTF). They're basically nutritionally fortified peanut butter manufactured to certain quality standards, and they're incredibly effective. Which brings me to MANA, or Mother-Administered Nutritive Aid (and yes, a Biblical reference). They're on a long list of things I've been meaning to write about, but my memory was jogged by their Somalia email blast. I'm a natural skeptic about start-up nonprofits, but over time they've won me over with their idea. The model is relatively simple: for now they're manufacturing RUTFs in the US and selling them to UNICEF and large NGOs that have established distribution networks. I like that aspect -- they're not trying to be all things to all men by distributing it themselves, as they've recognized that role is better done by others.

But the US manufacturing is just a stop-gap. For one, it's helping them learn the ropes on producing high quality RUTFs  and supplying these badly needed and under-produced goods to organizations with complicated purchasing requirements. Their end goal is to establish a self-sustaining (ie, profitable) manufacturing plant in Rwanda, and they're making progress on it.  A donation now will help them make more RUTFs and help them establish the Rwanda facility until it gets to a point where it no longer requires ongoing help.

One reason I think MANA is the right sort of group to establish such a business in Rwanda is that it's co-founded by Mark Moore, and he's well situated to work on both the problems of small enterprises in east Africa and international politics and supply chains. Like me, Mark is a Harding alum. He's a smart guy who spent ten years in eastern Uganda as a missionary (and started the Kibo Group development org), but he also has a Masters in development studies from Georgetown and served as Mary Landrieu's Africa specialist in the Senate. His work was the sort of evangelical aid I thought of when I read Dave Algo's recent post on how secular aid and development workers should be less hostile to good aid work done by evangelicals. Well, this it: in my opinion it's a smart business model run (an being an aspiring development professional, I'd welcome critical feedback in the comments as well) by people who can provide some necessary help to get things set up, and then step back out of the way. Once the facility is up and running in Rwanda it will mean more of our aid money can actually go into the east African economy as NGOs buy RUTFs from MANA and pay its local workers' wages.

Those who know me well or read this blog know that I have ambivalent feelings about Harding. I went there planning on being a medical missionary, and while I lost my faith I also made many friends, and my experiences there led me to my current interests in global health. So I have good things to say and bad things to say. One of the good things -- that I don't say enough -- is that there are a lot of incredibly sincere, hard-working people who come out of the school and do work that I couldn't find fault with if I tried. This is one of them, and I'm sure they'd appreciate your support.

Who is Sam Childers?

He goes by many names, Reverend Sam and the “Machine Gun Preacher” amongst them. If you haven’t heard much from Sam Childers, you will soon. To date he’s been featured in a few mainstream publications, but most of his exposure has come from forays into Christian media outlets and cross-country speaking tours of churches. In 2009 he published his memoir, Another Man’s War. But Childers is about to become much better known: his life story is being made into a movie titled Machine Gun Preacher. It hits the big screen this September, starring Gerard Butler (300) and directed by Oscar-winner Marc Forster (Monster’s Ball, Quantum of Solace).

Why should you care? If you’re concerned about Africa (especially the newly independent South Sudan), neutrality and humanitarianism, or how small charities sometimes make it big on dubious stories, Childers is a scary character. By his own admission Sam Childers is a Christian and a savior to hundreds of children, as well as a small-time arms-dealer and a killer. And, as far as I can tell, he’s a self-aggrandizing liar who chronically exaggerates his own stories and has been denounced by many, including the rebel group of which he claimed to be a commander.

It’s hard to get to the bottom of much of Childers’ story. I first heard of him months ago and have been scouring the web, but the trail is still pretty thin. On the on hand there’s a ton of copy written about him – but almost all of it originates with Childers’ own storytelling. I think there are a number of good reasons we should be skeptical.

The short version of his coming-to-the-big-screen story is this: Childers used to be a drug-dealing gang member who loved motorcycles almost as much as he craved women, drugs, and violence – especially violence. He fell in love with his wife after they met through a drug deal, and she convinced him to turn his life around. Sam found Jesus, got involved with the church, and went to Africa. There he encountered the Joseph Kony’s Lord’s Resistance Army and it use of child soldiers. He found his calling leading armed rescue missions to free enslaved children in northern Uganda and southern Sudan. Now that his life story is being made into a movie -- a goal Childers has long sought -- his ministry will only grow stronger and save more children.

His website, MachineGunPreacher.org, makes no apologies about his violent tactics. Here’s one of the banners that adorns the front page:

What you see now is a slickly-polished presentation, but it hasn’t always been that way. Childers’ story has grown over time, apparently aided by a PR firm, sympathetic media, and a quest to be ever more sensational. My gut reaction is that he’s making much of it up – and I’ll present evidence that shows at least some of his claims are likely falsehoods. We can choose to believe that Childers’ claims are true, in which case he is dangerous, or that they’re false and he’s untrustworthy. The reality is probably that he’s a bit of both.

This is part 1 of a longer article on Childers. Continue reading part 2 here, or you can read the whole series as one long article.

The Onion of Africa advocacy

"The Onion of Africa advocacy" is my new nickname for Falling Whistles, the Congo advocacy group that appears to be staffed more by graphic designers than people with policy chops or good taste. On first read it's hard to tell whether all of their material might actually be a big inside joke designed to mock tasteless, shallow advocacy messaging. Which would be awesome... except that they're serious. Their latest email, with the subject line "Announcing the Hamptons Edition Whistle" and a message body composed entirely of an image, is pasted below (click for larger version):

Judge for yourself?

Best practices of ranking aid best practices

Aid Watch has a post up by Claudia Williamson (a post-doc at DRI) about the "Best and Worst of Official Aid 2011". As Claudia summarizes, their paper looks at "five dimensions of agency ‘best practices’: aid transparency, minimal overhead costs, aid specialization, delivery to more effective channels, and selectivity of recipient countries based on poverty and good government" and calculates an overall agency score. Williamson notes that the "scores only reflect the above practices; they are NOT a measure of whether the agency’s aid is effective at achieving good results." Very true -- but I think this can be easily overlooked. In their paper Easterly and Williamson say:

We acknowledge that there is no direct evidence that our indirect measures necessarily map into improved impact of aid on the intended beneficiaries. We will also point out specific occasions where the relationship between our measures and desirable outcomes could be non-monotonic or ambiguous.

But still, grouping these things together into a single index may obscure more than it enlightens. Transparency seems more of an unambiguous good, whereas overhead percentages are less so. Some other criticisms from the comments section that I'd like to highlight include one from someone named Bula:

DfID scores high and USAID scores low because they have fundamentally different missions. I doubt anyone at USAID or State would attempt to say with a straight face that AID is anything other than a public diplomacy tool. DfID as a stand alone ministry has made a serious effort in all of the areas you’ve measured because it’s mission aligns more closely to ‘doing development’ and less with ‘public diplomacy’. Seems to be common sense.

And a comment from Tom that starts with a quote from the Aid Watch post:

“These scores only reflect the above practices; they are NOT a measure of whether the agency’s aid is effective at achieving good results.”

Seriously? How can you possibly give an aid agency a grade based solely on criteria that have no necessary relationship with aid effectiveness? It is your HYPOTHESIS that transparency, overhead, etc, significantly affect the quality of aid, but without looking at actual effeciveness that hypothesis is completely unproven. An A or an F means absolutely nothing in this context. Without looking at what the agency does with the aid (i.e. is it effective), why should we care whether an aid agency has low or high overhead? To take another example, an aid agency could be the least transparent but achieve the best results; which matters more, your ideological view of how an agency “should” function, or that they achieve results? In my mind it’s the ends that matter, and we should then determine what the best means are to achieve that result. You approach it with an a priori belief that those factors are the most important, and therefore risk having ideology overrule effectiveness. Isn’t that criticism the foundation of this blog and Dr. Easterly’s work more generally?

Terence at Waylaid Dialectic has three specific criticisms worth reading and then ends with this:

I can see the appeal, and utility of such indices, and the longitudinal data in this one are interesting, but still think the limitations outweigh the merits, at least in the way they’re used here. It’s an interesting paper but ultimately more about heat than light."

I'm not convinced the limitations outweigh the merits, but there are certainly problems. One is that the results quickly get condensed to "Britain, Japan and Germany do pretty well and the U.S. doesn’t."

Another problem is that without having some measure of aid effectiveness, it seems that this combined metric may be misleading -- analogous to a process indicator in a program evaluation. In that analogy, Program A might procure twice as many bednets as Program B, but that doesn't mean it's necessarily better, and for that you'd need to look at the impact on health outcomes. Maybe more nets is better. Or maybe the program that procures fewer bednets distributes them more intelligently and has a stronger impact. In the absence of data on health outcomes, is the process indicator useful or misleading? Well, it depends. If there's a strong correlation (or even a good reason to believe) that the process and impact indicators go together, then it's probably better than nothing. But if some of the aid best practices lead to better aid effectiveness, and some don't, then it's at best not very useful, and at worst will prompt agencies to move in the wrong direction.

As Easterly and Williamson note in their paper, they're merely looking at whether aid agencies do what aid agencies say should be their best practices. However, without a better idea of the correlation between those aid practices and outcomes for the people who are supposed to benefit from the programs, it's really hard to say whether this metric is (using Terence's words) "more heat than light."

It's a Catch-22: without information on the correlation between best aid practices and real aid effectiveness it's hard to say whether the best aid practices "process indicator" is enlightening or obfuscating, but if we had that data on actual aid effectiveness we would be looking at that rather than best practices in the first place.

The Tea Test

If you haven't been following it, there's currently a lot of controversy swirling around Greg Mortenson, co-author of Three Cups of Tea and co-founder of the Central Asia Institute. On Sunday 60 minutes aired accusations that Mortenson fabricated the 'creation myth' of the organization, a story about being kidnapped by the Taliban, and more. The blog Good Intentions Are Not Enough is compiling posts related to the emerging scandal, and the list is growing fast. If you haven't read it already, Jon Krakauer's mini-book, Three Cups of Deceit: How Greg Mortenson, Humanitarian Hero, Lost His Way, is really worth the read. Completely engrossing. It's a free download at byliner.com until April 20. It's about 90 pages, and Krakauer has obviously been researching it for a while -- in fact, my guess is that Krakauer turned 60 Minutes onto the story, rather than vice versa, which would help explain why he was featured so heavily in their piece. In the TV interview Krakauer quotes several former employees saying quite unflattering things about how CAI is run, so it's good to see that he gets many of those people on record in his ebook.

A few disclaimers: I think it's worth pointing out that a) as a one-time supporter and donor to CAI, Krakauer arguably has an axe to grind, b) several of Krakauer's previous books (Into Thin Air, Into the Wild, and Under the Banner of Heaven) have had sections disputed factually, though to me Into the Wild is the only case where he seems to have actually gotten things wrong, and c) I'm a big fan of him as a writer and thus am possibly a bit predisposed to believe him. Admitting by biases up front like good epidemiologist.

That said, it sounds like CAI has been very poorly led. Krakauer's book levels many damning claims about Mortenson and CIA's financial management that, while less emotionally shocking than the exaggerations about the 'creation myth,' should be much more troubling. CAI and Mortenson's responses to the accusations so far on 60 Minutes have seemed superficial, and I think it's safe to say that they will not come out of this looking squeaky clean.

I believe this episode raises two broader questions for the nonprofit community.

First, Krakauer chronicles a string of board members, employees, and consultants who came in, were shocked by how things were done and/or discovered discrepancies, and ended up leaving or resigning in protest. This section (pages 50-51) jumped out at me:

After Mortenson refused to comply with CFO Debbie Raynor's repeated requests to provide documentation for overseas programs, Raynor contacted Ghulam Parvi (the Pakistan program manager) directly, instructing him to provide her with documentation. For two or three months Parvi complied - until Mortenson found out what was going on and ordered Parvi to stop. Raynor resigned.

In 2007, Mortenson hired an accomplished consultant to periodically fly to Central Asia to supervise projects. When he discovered irregularities and shared them with Mortenson, Mortenson took no action to rectify the misconduct. In 2010, the consultant quit in frustration.

In September 2007, CAI hired a highly motivated, uncommonly capable woman to manage its international programs. Quickly, she demonstrated initiative and other leadership skills the Institute sorely needed. She had exceptional rapport with Pakistani women and girls. In 2008, she unearthed serious issues in Baltistan that contradicted what Mortenson had been reporting. After she told Mortenson about these problems, she assumed he would want her to address them. Instead, as she prepared to return to Pakistan in 2009, Mortenson ordered her to stay away from Baltistan. Disillusioned, she resigned in June 2010.

Seriously -- ff this has been going on for so long, how on earth is it just coming out now? Evidently a nationally known organization can have nearly its entire board resign and multiple employees quit, and it doesn't make the news until years later? Some of this (I'm speculating here) likely results from a hesitance on the part of those former employees to speak ill of CAI, whether because they still believed in its mission or because they were worried about being the sour grape person. Were they speaking out and nobody listened, or is there simply no good way to raise red flags about a nonprofit organization?

Second, while most organizations aren't guilty of fraud -- we hope -- there's at least one other take-away here. Another excerpt that jumped out at me:

On June 13, 2010, Parvi convened a meeting in Skardu to discuss Three Cups of Tea. Some thirty community leaders from throughout Baltistan participated, and most of them were outraged by the excerpts Parvi translated for them. Sheikh Muhammad Raza—chairman of the education committee at a refugee camp in Gultori village, where CAI has built a primary school for girls—angrily proposed charging Mortenson with the crime of fomenting sectarian unrest, and urged the District Administration to ban Mortenson and his books from Baltistan.

Based on Krakauer's footnotes, Parvi may be one of his less reliable sources, but this idea -- that the people portrayed in the book were outraged when it was translated to them because of how misleading it is -- comes up several times. Yes, fabricating stories is really bad. But how many other things do nonprofits say in their advertising that would be uncomfortable or downright offensive if you translated it for (and/or showed the accompanying pictures to) the recipients or beneficiaries or their services?

I propose a simple way to check this impulse -- to write about people as if they are victims or powerless -- and in honor of Three Cups of Tea, I call it the "Tea Test":

Step One: read the website content, blog posts, or email appeal you just got from your charity of choice. Or, if you work for a nonprofit organization, read your own stuff.

Step Two: imagine arriving in the recipient city or village, with a translated copy of that text. Would you be uncomfortable reading that website or blog or email to the people you met? Would it require tortured explanations, or would it instantly make sense and leave them feeling dignified?

That's it: if Step Two didn't make you cringe, then you passed the Tea Test. If it made you uncomfortable, made them feel ashamed, or got you attacked -- re-draft your copy and try again. Or find another organization to support.

I think there are many organizations that pass the Tea Test, but probably many more that fail. These organizations don't necessarily share all the faults of CAI as laid out by Krakauer and others, but they wouldn't fare much better in this situation, because they say something for one audience that was never intended to get back to the others.

I hope the idea of the Tea Test -- reading a translated copy of that material to the people it's describing -- will be helpful for donors and nonprofiteers alike. As a former online fundraiser I know I've broken this rule, and as a donor I've found things appealing that I probably should have reacted strongly against. I'm going to try to do better.

Update: I've posted a slightly revised (and I hope easier to remember) version of the Tea Test on a permanent page here.

Why World Vision should change, but won't

Note: I've edited the original title of this post to tone it down a bit. World Vision has recently come under fire for their plan to send 100,000 NFL t-shirts printed with the losing Super Bowl team to the developing world. This gifts-in-kind strategy was criticized by many bloggers -- good summaries are at More Altitude and Good Intentions are Not Enough. Saundra S. of Good Intentions also explained why she thinks there hasn't been as much reaction as you might expect in the aid blogosphere:

So why does Jason, who did not know any better, get a barrage of criticism. Yet World Vision, with decades of experience, does not? Is it because aid workers think that the World Vision gifts-in-kind is a better program? No, that’s not what I’m hearing behind the scenes. Is it because World Vision handled their initial response to the criticism better? That’s probably a small part of it, I think Jason’s original vlog stirred up people’s ire. But it’s only a small part of the silence. Is it because we are all sick to death of talking about the problems with donated goods? That’s likely a small part of it too. I, for one, am so tired of this issue that I’d love to never have to write about it again.

But in the end, the biggest reason for the silence is aid industry pressure. I’ve heard from a few aid workers that they can’t write - and some can’t even tweet – about the topic because they either work for World Vision or they work for another nonprofit that partners with World Vision. Even people that don’t work for a nonprofit are feeling pressure. One independent blogger told of receiving emails from friends that work at World Vision imploring them not to blog about the issue.

While I was one of the critical commentators on the original World Vision blog post about the NFL shirt strategy, I haven't written about it yet here, and I feel compelled by Saundra S.'s post to do so. [Disclosure: I've never worked for World Vision even in my consulting work and -- since I'm writing this -- probably never will, so my knowledge of the situation is gleaned solely from the recent controversy.]

And now World Vision has posted a long response to reader criticisms, albeit without actually linking to any of those criticisms -- bad netiquette if you ask me. Saundra S. responds to the World Vision post with this:

Easy claims to make, but can you back them up with documentation? Especially since other non-profits of similar size and mission - Oxfam, Save the Children, American Red Cross, Plan USA - claim very little as gifts-in-kind on their financial statements. So how is it that World Vision needs even more than the quarter of a billion dollars worth of gifts-in-kind each year to run their programs? To be believed, you will need to back up your claims with documentation including: needs assessments, a market analysis of what is available in the local markets and the impact on the market of donated goods (staff requests do not equal a market analysis), an independent evaluation of both the NFL donations (after 15 years you should have done at least one evaluation) and an independent evaluation of your entire gifts-in-kind portfolio. You should also share the math behind how World Vision determined that the NFL shirts had a Fair Market Value - on the date of donation - of approximately $20 each. And this doesn't even begin to hit on the issues with World Vision's marketing campaigns around GIK. Why keep perpetuating the Whites in Shining Armor image.

So to summarize Saundra S.'s remaining questions:

1. Can WV actually show that they rigorously assess the needs of the communities they work in for gift-in-kind (GIK)? especially beyond just "our staff requested them"?

2. Why does WV use a much larger share of GIK than other similarly sized nonprofits.

3. Has WV tried to really evaluate the results of this program? (If not, that's ridiculous after 15 years.)

4. How did WV calculate the 'fair market value' for these shirts? (This one has an impact on how honestly WV is marketing itself and its efficiency.)

Other commenters at the WV response (rgailey33 and "Bill Westerly") raise further questions:

5. Does WV know / care where the shirts come from and how their production impacts people?

6. Rather than apparently depending on big partners like the NFL to help spread the word about WV is doing and, yes, drive more potential donors to WV's website (not in itself a bad thing) shouldn't they be doing more to help partners like the NFL -- and the public they can reach -- realize that t-shirts aren't  a solution to global poverty? After all, wouldn't it be much more productive to include the NFL in a discussion of how to reform the global clothing and merchandise industries to be less exploitative?

7. WV must have spent a lot of money shipping these things... isn't there something better they could do with all that money? And expanding on that:

Opportunity cost, opportunity cost, opportunity cost. The primary reason I'm critical of  World Vision is that there are so many things they could be doing instead!

For a second, let's assume that GIK doesn't have any negative or positive effects -- let's pretend it has absolutely no impact whatsoever. (In fact, this may be a decently good approximation of reality.) Even then, WV would have to account for how much they spent on the programs. How much did WV spend in staff time, administrative costs like facilities, and field research by their local partners coordinating donations with NFL and other corporate groups? On receiving, sorting, shipping, paying import taxes, and distributing their gifts-in-kind? If they've distributed 375,000 shirts over the last few years, and done all of the background research they describe as being necessary to be sensitive to local needs... I'm sure it's  an awful lot of money, surely in the millions.

Amy at World Vision is right that their response will likely dispel some criticism, but not all. But that's not because we critics are a particularly cantankerous bunch -- we just think they could be doing better. Her response shows that, at least in one sense, they are a lot better than Jason of the 1 Million Shirts fiasco, if they're spreading the shirts out and doing local research on needs -- but those things are more about minimizing potential harm than they are maximizing impact. In short, World Vision's defense seems to be "hey, what we're doing isn't that bad" when really they should be saying "you know what? there are lots of things we could be doing instead of this that would be much greater impact." So in another way World Vision is much worse than Jason, because they have enough experts on these things to know what they're doing and that this sort of program has very little likelihood of pulling anyone out of poverty, they know there are better things they could be doing with the same money, and they still do it.

To get to why I think that's the case, let's go back to WV's response to the GIK controversy. From Amy:

At the same time, I’ll also let you know that, among our staff, there is a great deal of agreement with some of the criticisms that have been posted here and elsewhere in the blogosphere.  In my conversations, I’ve heard overwhelming agreement that product distribution done poorly and in isolation from other development work is, in fact, bad aid.  To be sure, no one at World Vision believes that a tee shirt, in and of itself, is going to improve living conditions and opportunities in developing communities. In addition, World Vision doesn’t claim that GIK work alone is sustainable.  In fact, no aid tactic, in and of itself, is sustainable.  But if used as a tool in good development work, GIK can facilitate good, sustainable development.

There are obviously a lot of well-intentioned and smart people at World Vision, and from this it sounds like there are differences of opinion as to the value of GIK aid. One charitable way of looking at the situation is to assume that employees at WV who doubt the program's impact justify its use as a marketing tool --  but if that's the case they should classify it as a marketing expense, not a programmatic one. But I imagine the doubts run deeper, but it's pretty hard for someone at any but the most senior of levels to greatly change things from inside the organization, because it's simply too ingrained in how WV works. Clusters of jobs at WV are probably devoted to tasks related to this part of their work: managing corporate partnerships, coordinating the logistics of the donations, and coordinating their distribution.

One small hope is that this controversy is giving cover to some of those internal critics, as the bad publicity associated with it may negate the positive marketing value they normally get from GIK programs. Maybe a public shaming is just what is needed?

[I really hope I get to respond to this post in 6 months or a year and say that I was wrong, that World Vision has eliminated the NFL program and greatly reduced their share of GIK programs... but I'm not holding my breathe.]

Haiti: Constancy and Change

A friend of mine recently moved to Haiti to work for a local organization. I've never been to Haiti, and as with many places to which I have yet to travel, it's difficult for me to picture the reality on the ground, especially when I know how much the places I've traveled to have differed from media reports and books I've read. While my friend and I were talking about Haiti, I mentioned that it would be interesting if I could email some questions and post the answers here on my blog. While I don't think any of the sentiments below are that controversial, I hope this will be a continuing series where I can ask questions and get frank answers (and share them with my readers), so we decided to keep it anonymous. I'll call my friend "F" here. Please let me know (in the comments or by email) if you have any questions you'd like me to relay to F for follow-up posts.

Brett: Can you tell me a little about how long you've been in Haiti, how long you lived there in the past, and what you're doing now (in a vague sense)?

F: I spent a nearly a year in Haiti in 2005-06. I always knew I'd be back some time, and after the earthquake on January 12th, 2010, I regretted that I hadn't returned sooner. I finally arrived back a few weeks ago, to take up a new position with the same organization I worked for five years ago.

Brett: How have things changed since the last time you were there? Did you have a lot of expectations about how things would be post-earthquake, and if so, how does the reality compare to what you were expecting?

F: Of course it's very sad to see so many landmarks in Port-au-Prince reduced to rubble, and what used to be great public spaces packed full of thousands and thousands of people living under tents and blue tarpaulins. Walking around the city is a little creepy: I'll wander down streets I know well, and find that a house or church I used to pass every day is gone.

But I've also been surprised by how much hasn't changed. The same fruit vendor I used to buy from five years ago still sits on the same street corner with her basket of oranges - even though the grocery store behind her has completely vanished. From my first morning back in the office, catching up with old friends and co-workers, it was as if I'd never left. Knowing how Haiti had switched from being a developing country to being (in international NGO terms) a humanitarian emergency, I think I was expecting to see some kind of fundamental change in the way things happen here. In reality, while the problems are perhaps more urgent now, the way of life is just the same as before.

Brett: What's the latest on cholera? Is everyone incredibly concerned, or is it just one crisis among many?

F: I think people see cholera as yet another disaster in a terrible year for the country. It's very sad that cholera seems most probably to have been brought here by the UN "assistance" force (which was already almost-universally reviled among Haitian people). However, I have to say I've been genuinely impressed with the speed and effectiveness of the response by the government and NGOs. I'm as cynical as anyone else about how little there is to show for years and years of public health efforts by international NGOs in Haiti: but this time, they seem to have got it more or less right. I arrived only two weeks after the outbreak started, and already by then everybody I met knew exactly what the steps for prevention were. I see people living in even the most basic conditions being meticulously careful about washing their hands and chlorinating their water.

Last week I was visiting a rural community, and I met a woman who was using water from an irrigation channel to wash her pots and pans. My colleagues, and also the local woman who was showing us around, were furious, telling her in no uncertain terms that her children will die of cholera if she continues doing that. But three months ago, it would have been completely normal.

Brett: What do you think I'm missing about Haiti from reading the news and the occasional blog?

F: Wow, where to start? I don't think that the journalistic staples of tent cities, cholera, rock-throwing demonstrators, and heroic Americans battling against poverty gives you much idea of what life in Haiti is really like. Perhaps what would most surprise an outsider is just how normal life here is most of the time. For example, Haiti was again in the international headlines with post-election protests in December. It's true that most people stayed at home for a couple of days while the situation was tense. But on the third day things started quietening down - and by the fourth day, the merchants were back on the streets, children were again hurrying to school in their little checkered uniforms, and the morning traffic jams were as bad as ever. Haitian people have seen a lot of political upheaval and many natural disasters over the years, they've seen international attention come and go, and life has carried on throughout.

There's a fascinating story waiting to be told about the social and economic effects of the 2010 earthquake. Almost every newspaper article I read about Haiti starts by describing it as the poorest country in the western hemisphere. That's true - but the situation is far more complex than that. This country has a lot of very poor people, but also quite a number of reasonably wealthy people too, and some super-rich. (Port-au-Prince has long had a Porsche dealership, believe it or not.) Before the earthquake, the level of inequality in Haiti was even higher than Brazil. Of course the earthquake was indiscriminate: it hit rich and poor alike, destroying the National Palace and the Montana Hotel as well as tens of thousands of single-room block-and-tin-roof houses. But this destruction of houses (combined with an enormous influx of foreigners, who all need a place to stay) has meant a huge increase in the price of accommodation, and a boom for landlords whose property was not damaged. My landlady is frantically adding extensions to our apartment building: that means she's employing a dozen or so construction workers, which is great. Some jobs are being created, but at the same time inflation is soaring. Then there's the complication of the massive internal migrations caused by the earthquake. I don't think anyone really knows what all this means for the long term, but it would be great to see some informed analysis.

Most of all, while there's a lot that's going wrong in Haiti, I wish the media would sometimes mention some of the great things about the country: the lively kompa music which surrounds you constantly in the street, the colorful, expressive language, the way Haitian people are so scrupulously polite and courteous (even among the urban youth, or more so than you'd expect), and the way they have such a strong sense of identity and of their proud history. Coming back has also made me realise how I had missed the Haitian sense of humor. When I get on a bus in the city and ask the people next to me how they're doing, I sometimes get a response of "lamizè ap kraze nou": "we're crushed by misery" - that seems to be the sort of thing people expect foreigners want to hear. But then more often than not, before we've gone a hundred yards down the road, my neighbors are laughing and joking with me - often teasing me about my terrible Creole. People here are certainly resilient: even after all the troubles and tragedy of the last 12 months, they are still able to find reasons to be cheerful.