"The opening deal"

I liked this quote from economist Karthik Muralidharan, which is pulled from a conversation at Ideas for India with Kaushik Basu of the World Bank:

My own take on what is happening in economics as a profession, talking to people in other disciplines, is that our fundamental weakness at some level is that because the touchstone of policy evaluation is the idea of a Pareto improvement (is someone better off and no one worse off) - effectively, economists do not question the justice of the initial positions. You kind of take the initial position as granted and say that conditional on this, how do I improve things on the margin.

Given vast inequalities in the opening deal of cards, so to speak, there is obviously a deep political need to create the space for more pro-poor policy. I think because the professional economists have abdicated that space to saying that it is a philosophical debate and we have really nothing to say, the rights-based movement that has created the political space for pro-poor policy has also then occupied the space of how to design it because they are the people who have created the political movement.

My own view on this is that because economists have kind of been seen as apologists for the status quo in many settings, we have lost the credibility to say that we are as pro-poor as you are, but conditional on these objectives there are much better ways to design it.

Lots on poverty policy, inequality, etc at the link.

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.)

Is there a global health bubble? (Or: should you get an MPH?)

There's a LinkedIn group for Global Public Health that occasionally has good discussion. One example, albeit a sobering one, is the current discussion of employment opportunities after MPH. I've been meaning to write about jobs for a while because now that I'm on the other side of the picture -- an employed professional with a job at a reputable organization, rather than a grad student -- I find myself doing an increasing number of informational interviews, and saying much the same thing each time.

[First, some caveats on the generalizability of the advice below: first, folks with an MPH from another country often have less debt burden than Americans, so may find it easier to do long unpaid or underpaid internships. Second, folks from low- to middle-income countries are and should be more employable, especially in their own countries. Why? Because they have incredibly valuable linguistic and cultural talents (see Alanna Shaikh's recent post on this), so much so that an organization choosing between an outsider and a local with the same technical skills, communication skills, etc, should almost always choose the local. If they don't, that's generally a sign of a dysfunctional or discriminatory organizations.]

The problem is that there is something of an MPH bubble, especially in global health. The size of MPH classes has increased and - more importantly - the number of schools granting degrees has risen rapidly. Degrees focusing on global health also seem to be growing faster than the rest of the field.  (I'd welcome data on class size and jobs in the industry if anyone knows where to find it.) This is happening in part because public health attracts a lot of idealists who are interested in the field because they want to make a difference, rather than rationally choosing between the best paying jobs, and global health has gotten a lot of good press over the last decade. Call this the Mountains Beyond Mountains Effect if you like.

If you know this, and still go into the field, and don't have an MD or PhD that qualifies you for a different sort of job altogether, then you need to distinguish yourself from the crowd to be employable. I'm assuming your goal is to get a good job in global health, where "good job" is defined as a full-time professional position with a good (not necessarily big-name) organization, working on fulfilling projects and being paid well enough to live comfortably while paying off the loans that most American MPH grads will have. For some, though not all, a good job might also mean one that's either based abroad or involves frequent international travel. If that's the goal, then there are several ways to distinguish yourself:

1. get some sort of hard, transferable skills. This can be research or M&E skills, especially quantitative data crunching ability, or it can be management/coordination experience with serious responsibility. Or other things. The key point is that your skillset should match jobs that are out there, and be something that not everyone has. A lot of MPH programs feature concentrations -- or the lack thereof -- that are more appealing to students than they are to employers. A biostatistics concentration will likely serve you better than a global health concentration, for instance, and with some exceptions.
2. get solid international experience, preferably a year or more. Professional experience in public health -- even with a lesser-known organization -- is much more valuable than experience teaching, or studying abroad. Travel doesn't count much, and it's better to have experience in the region you're interested in working in. There's a huge catch-22 here, as you need international experience to get it, so that many global health folks start off doing work they're critical of later in their careers.
3. relatedly, speak an in-demand language, though this will only help you to work in the region where it's spoken.
4. have professional work experience. Even if it's not in global health, having worked an office job for a year or two makes you more desirable to employers. No one wants to be your first employer, so folks who go straight to an MPH may find themselves less employable than peers who worked for a bit first.
5. go to a top school, which signals that you're smarter or better qualified than others (this often isn't true, the key part is the signalling, and the networks you acquire). Also, graduates of top schools often get good jobs in part because those schools select people with good work experience, skills, and connections to begin with, so that a superior candidate at a school that's perceived to be a second or third-tier school can do just fine.
6. avoid debt (which often conflicts with 'go to a top school') to give yourself the flexibility to work for less or for nothing at first, until you can do the above.

Any one or two items from this list probably won't cut it: you need to acquire several.  For example, I've known peers with a solid technical degree from a top school and some international experience who still struggled to get jobs at first because they had never had a regular office job before grad school. Also, the relative importance of each will vary according to the subfield of global health you're interested in. For instance, learning languages might be more important for an implementation person (program coordinator or manager) or a qualitative researcher than it is for a data cruncher.

I used to be pre-med, until I realized I was more interested in policy and did not want to be a clinician, and the path to doing so in the US is long and expensive. Like many former pre-med students who decided not to go to medical school, it took me a while to figure out what I wanted to do, and how to do that without an MD. A couple years post-undergrad I found myself working a job that was interesting enough but not what I ultimately wanted to do, and unable to get a first job in global health without the requisite skills or longer international experience, and I didn't have the resources to just up and move abroad on my own. So, I went to go to grad school with a technical focus (epidemiology) at a top school, and then used the practicum requirement to build more international experience (Ethiopia). The combination of school and work experience gave me solid quantitative skills because I chose to focus on that each step of the way. But, it also meant taking on quite a bit of debt, and the international practicum would have required even more had I not had generous funding from the econ/policy degree I did. This has worked out well for me, though that same path won't necessarily work for everyone -- especially if you have different interests from mine! -- and I think it's instructive enough to share.

The upside of this bubble is that organizations often hire well-educated, experienced people for even entry level position. The downside is that people from less privileged educational or financial backgrounds often get blocked out of the sector, given that you might have to volunteer for an extended period of time to get the requisite experience, or take on a lot of debt to get a good graduate degree.

In conclusion, getting an MPH -- and trying to break into global health -- is a personal decision that might work out differently depending on your personal goals, the lifestyle you're looking for, and your financial background. But if you do get one, be aware that the job market is not the easiest to navigate, and many MPH grads end up unemployed or underemployed for a stretch. Focus on acquiring the skills and experience that will make organizations want to hire you.

Data: big, small, and meta

When I read this New York Times piece back in August, I was in the midst of preparation and training for data collection at rural health facilities in Zambia. The Times piece profiles a group called Global Pulse that is doing good work on the 'big data' side of global health:

The efforts by Global Pulse and a growing collection of scientists at universities, companies and nonprofit groups have been given the label “Big Data for development.” It is a field of great opportunity and challenge. The goal, the scientists involved agree, is to bring real-time monitoring and prediction to development and aid programs. Projects and policies, they say, can move faster, adapt to changing circumstances and be more effective, helping to lift more communities out of poverty and even save lives.

Since I was gearing up for 'field work' (more on that here; I'll get to it soon), I was struck at the time by the very different challenges one faces at the other end of the spectrum. Call it small data? And I connected the Global Pulse profile with this, by Wayan Vota, from just a few days before:

The Sneakernet Reality of Big Data in Africa

When I hear people talking about “big data” in the developing world, I always picture the school administrator I met in Tanzania and the reality of sneakernet data transmissions processes.

The school level administrator has more data than he knows what to do with. Years and years of student grades recorded in notebooks – the hand-written on paper kind of notebooks. Each teacher records her student attendance and grades in one notebook, which the principal then records in his notebook. At the local district level, each principal’s notebook is recorded into a master dataset for that area, which is then aggregated at the regional, state, and national level in even more hand-written journals... Finally, it reaches the Minister of Education as a printed-out computer-generated report, complied by ministerial staff from those journals that finally make it to the ministry, and are not destroyed by water, rot, insects, or just plain misplacement or loss. Note that no where along the way is this data digitized and even at the ministerial level, the data isn’t necessarily deeply analyzed or shared widely....

And to be realistic, until countries invest in this basic, unsexy, and often ignored level of infrastructure, we’ll never have “big data” nor Open Data in Tanzania or anywhere else. (Read the rest here.)

Right on. And sure enough two weeks later I found myself elbow-deep in data that looked like this -- "Sneakernet" in action:

In many countries a quite a lot of data -- of varying quality -- exists, but it's often formatted like the above. Optimistically, it may get used for local decisions, and eventually for high-level policy decisions when it's months or years out of date. There's a lot of hard, good work being done to improve these systems (more often by residents of low-income countries, sometimes by foreigners), but still far too little. This data is certainly primary, in the sense that was collected on individuals, or by facilities, or about communities, but there are huge problems with quality, and with the sneakernet by which it gets back to policymakers, researchers, and (sometimes) citizens.

For the sake of quick reference, I keep a folder on my computer that has -- for each of the countries I work in -- most of the major recent ultimate sources of nationally-representative health data. All too often the only high-quality ultimate source is the most recent Demographic and Health Survey, surely one of the greatest public goods provided by the US government's aid agency. (I think I'm paraphrasing Angus Deaton here, but can't recall the source.) When I spent a summer doing epidemiology research with the New York City Department of Health and Mental Hygiene, I was struck by just how many rich data sources there were to draw on, at least compared to low-income countries. Very often there just isn't much primary data on which to build.

On the other end of the spectrum is what you might call the metadata of global health. When I think about the work the folks I know in global health -- classmates, professors, acquaintances, and occasionally thought not often me -- do day to day, much of it is generating metadata. This is research or analysis derived from the primary data, and thus relying on its quality. It's usually smart, almost always well-intentioned, and often well-packaged, but this towering edifice of effort is erected over a foundation of primary data; the metadata sometimes gives the appearance of being primary, when you dig down the sources often point back to those one or three ultimate data sources.

That's not to say that generating this metadata is bad: for instance, modeling impacts of policy decisions given the best available data is still the best way to sift through competing health policy priorities if you want to have the greatest impact. Or a more cynical take: the technocratic nature of global health decision-making requires that we either have this data or, in its absence, impute it. But regardless of the value of certain targeted bits of the metadata, there's the question of the overall balance of investment in primary vs. secondary-to-meta data, and my view -- somewhat ironically derived entirely from anecdotes -- is that we should be investing a lot more in the former.

One way to frame this trade-off is to ask, when considering a research project or academic institute or whatnot, whether the money spent on that project might result in more value for money if it was spent instead training data collectors and statistics offices, or supporting primary data collection (e.g., funding household surveys) in low-income countries. I think in many cases the answer will be clear, perhaps to everyone except those directly generating the metadata.

That does not mean that none of this metadata is worthwhile. On the contrary, some of it is absolutely essential. But a lot isn't, and there are opportunity costs to any investment, a choice between investing in data collection and statistics systems in low-income countries, vs. research projects where most of the money will ultimately stay in high-income countries, and the causal pathway to impact is much less direct.  

Looping back to the original link, one way to think of the 'big data' efforts like Global Pulse is that they're not metadata at all, but an attempt to find new sources of primary data. Because there are so few good sources of data that get funded, or that filter through the sneakernet, the hope is that mobile phone usage and search terms and whatnot can be mined to give us entirely new primary data, on which to build new pyramids of metadata, and with which to make policy decisions, skipping the sneakernet altogether. That would be pretty cool if it works out.

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.

Spreading the word

If you haven't already read Atul Gawande's latest New Yorker piece on why some ideas spread fast and other spread slow, get to it:

 In the era of the iPhone, Facebook, and Twitter, we’ve become enamored of ideas that spread as effortlessly as ether. We want frictionless, “turnkey” solutions to the major difficulties of the world—hunger, disease, poverty. We prefer instructional videos to teachers, drones to troops, incentives to institutions. People and institutions can feel messy and anachronistic. They introduce, as the engineers put it, uncontrolled variability.

But technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread. Mass media can introduce a new idea to people. But, Rogers showed, people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.

Much of the material is Gawande's essay won't be new if you're already interested in or working on maternal and child health, but Gawande presents it incredibly well. His comparison of spreading social innovation with the work of salesman also reminded me of another parallel: the parallels between diffusing secular, health-enhancing ideas and missionaries' evangelistic techniques.

If that last sentence scares you off, hold on a moment for some background. I grew up in a small religious town in Arkansas and my first trips to developing countries were as a missionary. Over time my interests shifted from the preaching and teaching side of things to the medical side, and eventually to health and development policy as an entirely secular pursuit. When I first got to grad school for public health this resulted in some awkward moments, as many conversations would start with "so what first interested you in global health?" If I led with "well, I grew up wanting to be a missionary" I would often get one of two reactions: immediate skepticism of my motivations from my secular liberal classmates, or enthusiastic endorsement of my work (as they misunderstood it) from religious classmates. All that to say: while I think there are very good general reasons to keep public health and missionary efforts as separate as possible, both in theory and praxis, there are several things we secular liberals can still learn from the more devout.

One example is the neverending debates amongst evangelists between those who seek technological shortcuts and those who stick with old-fashioned person-to-person contact. This is a frequent topic at missions conferences (if you didn't know such conferences existed, it might be an interesting google). You can view the rise of Christian radio broadcasts, followed by Christian TV and televangelists, as the great technological shortcuts: they give a single preacher the ability to reach millions, and if the message is just as good as when delivered in person, why shouldn't it be just as effective? Some people are persuaded by televangelists, of course, but the effectiveness of the individual doesn't scale easily to mass media. Likewise, in recent years there's been much enthusiasm for social media and its potential to save more souls -- but the results rarely pan out.  So despite all of the advances in mass and social media, most evangelists still harp on the importance of individual contact, of building relationships. One of the most effective (in terms of growth rate) groups in the world are Mormons, who, no coincidence, devote years of effort to one-on-one contact.

Gawande's essay tells the story of how BRAC precipitated oral rehydration solution in Bangladesh, and I couldn't help thinking of their campaign  as a sort of especially successful roving gospel meeting. And here's Gawande's closing, where he talks with a nurse who was convinced by a younger, less-experienced trainer to adopt some best practices for safe childbirth:

 “Why did you listen to her?” I [Gawande] asked. “She had only a fraction of your experience.”

In the beginning, she didn’t, the nurse admitted. “The first day she came, I felt the workload on my head was increasing.” From the second time, however, the nurse began feeling better about the visits. She even began looking forward to them.

“Why?” I asked.

All the nurse could think to say was “She was nice.”

“She was nice?”

“She smiled a lot.”

“That was it?”

“It wasn’t like talking to someone who was trying to find mistakes,” she said. “It was like talking to a friend.”

Shortcuts are nice: in public health, unlike evangelism, it's usually actions rather than beliefs that ultimately count, so I'm all for technological shortcuts when they're available and effective. But they're too few and far between, and much of the low-hanging fruit in global health has already been picked. To climb the next step require a lot more effort at improving the "messy and anachronistic"  processes of people and institutions.

Advocates and scientists

A new book by The Idealist: Jeffrey Sachs and the Quest to End Poverty. The blurbs on Amazon are fascinating because they indicate that either the reviewers didn't actually read the book (which wouldn't be all that surprising) or that Munk's book paints a nuanced enough picture that readers can come away with very different views on what it actually proves. Here are two examples:

Amartya Sen: “Nina Munk’s book is an excellent – and moving – tribute to the vision and commitment of Jeffrey Sachs, as well as an enlightening account of how much can be achieved by reasoned determination.”

Robert Calderisi: "A powerful exposé of hubris run amok, drawing on touching accounts of real-life heroes fighting poverty on the front line."

The publisher's description seems to encompass both of those points of view: "The Idealist is the profound and moving story of what happens when the abstract theories of a brilliant, driven man meet the reality of human life." That sounds like a good read to me -- I look forward to reading when it comes out in September.

Munk's previous reporting strikes a similar tone. For example, here's an excerpt of her 2007 Vanity Fair profile of Sachs:

Leaving the region of Dertu, sitting in the back of an ancient Land Rover, I'm reminded of a meeting I had with Simon Bland, head of Britain's Department for International Development in Kenya. Referring to the Millennium Villages Project, and to Sachs in particular, Bland laid it out for me in plain terms: "I want to say, 'What concept are you trying to prove?' Because I know that if you spend enough money on each person in a village you will change their lives. If you put in enough resources—enough foreigners, technical assistance, and money—lives change. We know that. I've been doing it for years. I've lived and worked on and managed [development] projects.

"The problem is," he added, "when you walk away, what happens?"

Someone -- I think it was Chris Blattman, but I can't find the specific post -- wondered a while back whether too much attention has been given to the Millennium Villages Project. After all, the line of thinking goes, the MVP's have really just gotten more press and aren't that different from the many other projects with even less rigorous evaluation designs. That's certainly true: when journalists and aid bloggers debate the MVPs, part of what they're debating is Sachs himself because he's such a polarizing personality. If you really care about aid policy, and the uses of evidence in that policy, then that can all feel like an unhelpful distraction. Most aid efforts don't get book-length profiles, and the interest in Sachs' personality and persona will probably drive the interest in Munk's book.

But I also think the MVP debates have been healthy and interesting -- and ultimately deserving of most of the heat generated -- because they're about a central tension within aid and development, as well as other fields where research intersects with activism. If you think we already generally know what to do, then it makes sense to push forward with it at all costs. The naysayers who doubt you are unhelpful skeptics who are on some level ethically culpable for blocking good work. If you think the evidence is not yet in, then it makes more sense to function more like a scientist, collecting the evidence needed to make good decisions in the longer term. The naysayers opposing the scientists are then utopian advocates who throw millions at unproven projects. I've seen a similar tension within the field of public health, between those who see themselves primarily as advocates and those who see themselves as scientists, and I'm sure it exists elsewhere as well.

That is, of course, a caricature -- few people fall completely on one side of the advocates vs. scientists divide. But I think the caricature is a useful one for framing arguments. The fundamental disagreement is usually not about whether evidence should be used to inform efforts to end poverty or improve health or advance any other goal. Instead, the disagreement is often over what the current state of knowledge is. And on that note, if you harbor any doubts on where Sachs has positioned himself on that spectrum here's the beginning of Munk's 2007 profile:

In the respected opinion of Jeffrey David Sachs.... the problem of extreme poverty can be solved. In fact, the problem can be solved "easily." "We have enough on the planet to make sure, easily, that people aren't dying of their poverty. That's the basic truth," he tells me firmly, without a doubt.

...To Sachs, the end of poverty justifies the means. By hook or by crook, relentlessly, he has done more than anyone else to move the issue of global poverty into the mainstream—to force the developed world to consider his utopian thesis: with enough focus, enough determination, and, especially, enough money, extreme poverty can finally be eradicated.

Once, when I asked what kept him going at this frenzied pace, he snapped back, "If you haven't noticed, people are dying. It's an emergency."

----

via Gabriel Demombynes.

If you're new to the Millennium Villages debate, here's some background reading: a recent piece in Foreign Policy by Paul Starobin, and some good posts by Chris Blattman (one, two, three), this gem from Owen Barder, and Michael Clemens.

Americanah

Americanah, the new novel by Chimamanda Ngozi Adichie is very good. I have a long list of Nigerian fiction on my to-read list, but Americanah got bumped to the top because it seemed like the perfect transition from Princeton to Nigeria: I heard Chimamanda speak in Princeton – where she, like Ifemelu, the main character, lived for a year on a fellowship – a month or so ago. Americanah starts with Ifemelu taking NJ Transit from Princeton to Trenton to get her hair braided, because Princeton is the sort of place with an “ice cream shop that had fifty different flavors including red pepper” but no one to braid black hair. Following her TED Talk advice, Americanah crams in many narratives. It’s set in Lagos and London, Brooklyn and Baltimore, New Haven and Philly, and it’s about migration from Lagos to America, from Lagos to London, and from everywhere back to Nigeria. One character, in London:

His eyes would follow them, with a lost longing, and he would think: You can work, you are legal, you are visible, and you don’t even know how fortunate you are.

It’s about dating across race, wealth, and cultures; academics and intellectuals and the many people who are only one or the other, not both; the London black market of arranged sham marriages and faked ID documents; accents real and faked; sex work; the constant burdens and exploitation and desperation of the undocumented; Barack Obama; the hope and opportunity that can come with an approved visa application; and hair. Lots of hair.

There are Americans who deny that racism is still a problem. Wealthy folks who, learning Ifemelu is from Nigeria, try to connect by mentioning their latest trip to Tanzania, their opinion of Ethiopian beauty, the charity they support in Malawi. Ifemelu thinks:

There was a certain luxury to charity that she could not identify with and did not have…. Ifemelu wanted, suddenly and desperately, to be from the country of people who gave and not those who received, to be one of those who had and could therefore bask in the grace of having given, to be among those who could afford copious pithy and empathy.

Another character is at a London dinner party, thinking:

Alexa, and the other guests, and perhaps even Georgina, all understood the fleeing from war, form the kind of poverty that crushed human souls, but they would not understand the need to escape form the oppressive lethargy of choicelessness. They would not understand why people like him, who were raised well fed and watered but mired in dissatisfaction, conditioned from birth to look towards somewhere else, eternally convinced that real lives happened in that somewhere else, were now resolved to do dangerous things, illegal things, so as to leave, none of them starving, or raped, or from burned villages, but merely hungry for choice and certainty.

Ifemelu is, for a while, a blogger who writes “Raceteenth or Various Observations About American Blacks (Those Formerly Known as Negroes) by a Non-American Black” which gives Adichie a venue to make observations, often hilarious and/or impolite. One post starts:

Dear Non-American Black, when you make the choice to come to America, you become black. Stop arguing. Stop saying I’m Jamaican or I’m Ghanaian. America doesn’t care. So what if you weren’t “black” in your country? You’re in America now….

Americanah never dwells on a single theme until it becomes tiresome The major characters are sympathetic but flawed, and the observations are constantly insightful – I wanted to quote much more here. So, highly recommended.

Several job opps

•  The Center for Global Development is hiring a Research Assistant for its work on global health policy; ideally this would be someone with a couple years of research work experience already. The outgoing person from this position spoke highly of their time there, so I'd recommend it.
• Three jobs with CHAI: 1) Analyst, Family Planning, 2) 3DE Program Manager, and 3) Project Manager, eLearning and Telemedicine. All via Karen Grepin on Twitter (a good person to follow for links and job listings).
• And see Chris Blattman re: a position he's hiring for in Ethiopia.

Some other good places to look for jobs: mHealth student Google group and the African Development Jobs blog.

"What is wrong (and right) in economics?"

Economist Dani Rodrik has a great essay up on his website on what's good and bad about economics. Here's a bit on the relationship between trade policy and growth:

I remember well the reception I got when I presented my paper (with Francisco Rodriguez) on the empirics of trade policy and growth. The literature had filled up with extravagant claims about the effect of trade liberalization on economic growth. What we showed in our paper is that the research to date could not support those claims. Neither the theoretical nor empirical literature indicated there is a robust, predictable, and quantitatively large effect of trade liberalization on growth. We were simply stating what any well-trained economist should have known. Nevertheless, the paper was highly controversial. One of my Harvard colleagues asked me in the Q&A session: “why are you doing this?” It was a stunning question. It was as if knowledge of a certain kind was dangerous.

There's a lot of good material in there about what economics is and isn't, and how to do it better.  I had forgotten that Rodrik studied at Princeton, so was pleasantly surprised by this:

However, contemporary economics in North America has one great weakness, and that is the excessive focus on methods at the expense of breadth in terms of social and historical perspective. PhD programs now train applied mathematicians and statisticians rather than real economists. To become a true economist, you need to do all sorts of reading – from history, sociology, and political science among other disciplines – that you are never required to do as a graduate student. The best economists today find a way of filling this gap in their education. I consider myself very lucky that I was a political science major and did a master’s in public affairs (as it is called at Princeton) before I turned to economics. I say lucky, because some of my best work – by my judgement, at least – was stimulated by questions or arguments I encountered outside of neoclassical economics.

(Not) knowing it all along

David McKenzie is one of the guys behind the World Bank's excellent and incredibly wonky Development Impact blog. He came to Princeton to present on a new paper with Gustavo Henrique de Andrade and Miriam Bruhn, "A Helping Hand or the Long Arm of the Law? Experimental evidence on what governments can do to formalize firms" (PDF). The subject matter -- trying to get small, informal companies to register with the government -- is outside my area of expertise. But I thought there were a couple methodologically interesting bits: First, there's an interesting ethical dimension, as one of their several interventions tested was increasing the likelihood that a firm would be visited by a government inspector (i.e., that the law would be enforced). From page 10:

In particular, if a firm owner were interviewed about their formality status, it may not be considered ethical to then use this information to potentially assign an inspector to visit them. Even if it were considered ethical (since the government has a right to ask firm owners about their formality status, and also a right to conduct inspections), we were still concerned that individuals who were interviewed in a baseline survey and then received an inspection may be unwilling to respond to a follow-up. Therefore a listing stage was done which did not involve talking to the firm owner.

In other words, all their baseline data was collected without actually talking to the firms they were studying -- check out the paper for more on how they did that.

Second, they did something that could (and maybe should) be incorporated into many evaluations with relative ease. Because findings often seem obvious after we hear them, McKenzie et al. asked the government staff whose program they were evaluating to estimate what the impact would be before the results were in. Here's that section (emphasis added):

A standard question with impact evaluations is whether they deliver new knowledge or merely formally confirm the beliefs that policymakers already have (Groh et al, 2012). In order to measure whether the results differ from what was anticipated, in January 2012 (before any results were known) we elicited the expectations of the Descomplicar [government policy] team as to what they thought the impacts of the different treatments would be. Their team expected that 4 percent of the control group would register for SIMPLES [the formalization program] between the baseline and follow-up surveys. We see from Table 7 that this is an overestimate...

They then expected the communication only group to double this rate, so that 8 percent would register, that the free cost treatment would lead to 15 percent registering, and that the inspector treatment would lead to 25 percent registering.... The zero or negative impacts of the communication and free cost treatments therefore are a surprise. The overall impact of the inspector treatment is much lower than expected, but is in line with the IV estimates, suggesting the Descomplicar team have a reasonable sense of what to expect when an inspection actually occurs, but may have overestimated the amount of new inspections that would take place. Their expectation of a lack of impact for the indirect inspector treatment was also accurate.

This establishes exactly what in the results was a surprise and what wasn't. It might also make sense for researchers to ask both the policymakers they're working with and some group of researchers who study the same subject to give such responses; it would certainly help make a case for the value of (some) studies.

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...

On regressions and thinking

Thesis: thinking quantitatively changes the way we frame and answer questions in ways we often don't notice. James Robinson, of Acemoglu and Robinson fame (ie, Why Nations Fail, @whynationsfail, Colonial Origins; Reversal of Fortune, and so forth), gave a talk at Princeton last week. It was a good talk, mostly about Why Nations Fail. My main thought during his presentation was that it's simply very difficult to develop a parsimonious theory that covers something as complicated as the long-term economic and political development of the entire world! As Robinson said (quoting someone else), in social science you can say "more and more about less and less, or less and less about more and more."

The talk was followed by some great discussion where several of the tougher questions came from sociologists and political economists. I think it's safe to say that a lot of the skepticism of the Why Nations Fail thesis is centered around the beef that East Asian economics, and especially China, don't fit neatly into it. A&R argue here on their blog -- not to mention in their book, which I've alas only had time to skim -- that China is not an exception to their theory, but I think that impression is still fairly widespread.

But my point isn't about the extent to which China fits into the theory (that's another debate altogether); it's about what it means if or when China doesn't fit into the theory. Is that a major failure or a minor one?  I think different answers to that question are ultimately rooted in a difference of methodological cultures in the social science world.

As social science becomes more quantitative, our default method for thinking about a subject can shift, and we might not even notice that it's happening. For example, if your main form of evidence for a theory is a series of cross-country regressions, then you automatically start to think of countries as the unit of analysis, and, importantly, as being more or less equally weighted. There are natural and arguably inevitable reasons why this will be the case: states are the clearest politicoeconomic units, and even if they weren't they're simply the unit for which we have the most data. While you might (and almost certainly should!) weight your data points by population if you were looking at something like health or individual wealth or well-being, it makes less sense when you're talking about country-level phenomena like economic growth rates. So you end up seeing a lot of arguments made with scatterplots of countries and fitted lines -- and you start to think that way intuitively.

When we switch back to narrative forms of thinking, this is less true: I think we all agree that all things being equal a theory that explains everything except Mauritius is better than a theory that explains everything except China. But it's a lot harder to think intuitively about these things when you have a bunch of variables in play at the same time, which is one reason why multiple regressions are so useful. And between the extremes of weighting all countries equally and weighting them by population are a lot of potentially more reasonable ways of balancing the two concerns, that unfortunately would involve a lot of arbitrary decisions regarding weighting...

This is a thought I've been stewing on for a while, and it's reinforced whenever I hear the language of quantitative analysis working its way into qualitative discussions -- for instance, Robinson said at one point that "all that is in the error term," when he wasn't actually talking about a regression. I do this sort of thing too, and don't think there's anything necessarily wrong with it -- until there is.  When questioned on China, Robinson answered briefly and then transitioned to talking about the Philippines, rather than just concentrating on China. If the theory doesn't explain China (at least to the satisfaction of many), a nation of 1.3 billion, then explaining a country of 90 million is less impressive. How impressive you find an argument depends in part on the importance you ascribe to the outliers, and that depends in part on whether you were trained in the narrative way of thinking, where huge countries are hugely important, or the regression way of thinking, where all countries are equally important units of analysis.

[The first half of my last semester of school is shaping up to be much busier than expected -- my course schedule is severely front-loaded -- so blogging has been intermittent. Thus I'll try and do more quick posts like this rather than waiting for the time to flesh out an idea more fully.]

Growth and stagnation in global health funding

Amanda Glassman of CGD shares the graph below from the latest IHME "Financing Global Health" report, which tells the top-line story from the report in one neat picture:

This year's report is subtitled, "The End of the Golden Age?" Maybe. I'd start with Amanda's analysis here, then dive into the report overview [PDF].

Alwyn Young just broke your regression

Alwyn Young -- the same guy whose paper carefully accounting for growth in East Asian was popularized by Krugman and sparked an enormous debate -- has been circulating a paper on African growth rates. Here's the 2009 version (PDF) and October 2012 version. The abstract of the latter paper:

Measures of real consumption based upon the ownership of durable goods, the quality of housing, the health and mortality of children, the education of youth and the allocation of female time in the household indicate that sub-Saharan living standards have, for the past two decades, been growing about 3.4 to 3.7 percent per annum, i.e. three and a half to four times the rate indicated in international data sets. (emphasis added)

The Demographic and Health Surveys are large-scale nationally-representative surveys of health, family planning, and related modules that tend to ask the same questions across different countries and over large periods of time. They have major limitations, but in the absence of high-quality data from governments they're often the best source for national health data. The DHS doesn't collect much economic data, but they do ask about ownership of certain durable goods (like TVs, toilets, etc), and the answers to these questions are used to construct a wealth index that is very useful for studies of health equity -- something I'm taking advantage of in my current work. (As an aside, this excellent report from Measure DHS (PDF) describes the history of the wealth index.)

What Young has done is to take this durable asset data from many DHS surveys and try to estimate a measure of GDP growth from actually-measured data, rather than the (arguably) sketchier methods typically used to get national GDP numbers in many African countries. Not all countries are represented at any given point in time in the body of DHS data, which is why he ends up with a very-unbalanced panel data set for "Africa," rather than being able to measure growth rates in individual countries. All the data and code for the paper are available here.

Young's methods themselves are certain to spark ongoing debate (see commentary and links from Tyler Cowen and Chris Blattman), so this is far from settled -- and may well never be. The takeaway is probably not that Young's numbers are right so much as that there's a lot of data out there that we shouldn't trust very much, and that transparency about the sources and methodology behind data, official or not, is very helpful. I just wanted to raise one question: if Young's data is right, just how many published papers are wrong?

There is a huge literature on cross-country growth 's empirics. A Google Scholar search for "cross-country growth Africa" turns up 62,400 results. While not all of these papers are using African countries' GDPs as an outcome, a lot of them are. This literature has many failings which have been duly pointed out by Bill Easterly and many others, to the extent that an up-and-coming economist is likely to steer away from this sort of work for fear of being mocked. Relatedly, in Acemoglu and Robinson's recent and entertaining take-down of Jeff Sachs, one of their insults criticisms is that Sachs only knows something because he's been running "kitchen sink growth regressions."

Young's paper just adds more fuel to that fire. If African GDP growth has been 3 1/2 to 4 times greater than the official data says, then every single paper that uses the old GDP numbers is now even more suspect.

On deworming

GiveWell's Alexander Berger just posted a more in-depth blog review of the (hugely impactful) Miguel and Kremer deworming study. Here's some background: the Cochrane review, Givewell's first response to it, and IPA's very critical response. I've been meaning to blog on this since the new Cochrane review came out, but haven't had time to do the subject justice by really digging into all the papers. So I hope you'll forgive me for just sharing the comment I left at the latest GiveWell post, as it's basically what I was going to blog anyway:

Thanks for this interesting review — I especially appreciate that the authors [Miguel and Kremer] shared the material necessary for you [GiveWell] to examine their results in more depth, and that you talk through your thought process.

However, one thing you highlighted in your post on the new Cochrane review that isn’t mentioned here, and which I thought was much more important than the doubts about this Miguel and Kremer study, was that there have been so many other studies that did not find large effect on health outcomes! I’ve been meaning to write a long blog post about this when I really have time to dig into the references, but since I’m mid-thesis I’ll disclaim that this quick comment is based on recollection of the Cochrane review and your and IPA’s previous blog posts, so forgive me if I misremember something.

The Miguel and Kremer study gets a lot of attention in part because it had big effects, and in part because it measured outcomes that many (most?) other deworming studies hadn’t measured — but it’s not as if we believe these outcomes to be completely unrelated. This is a case where what we believe the underlying causal mechanism for the social effects to be is hugely important. For the epidemiologists reading, imagine this as a DAG (a directed acyclic graph) where the mechanism is “deworming -> better health -> better school attendance and cognitive function -> long-term social/economic outcomes.” That’s at least how I assume the mechanism is hypothesized.

So while the other studies don’t measure the social outcomes, it’s harder for me to imagine how deworming could have a very large effect on school and social/economic outcomes without first having an effect on (some) health outcomes — since the social outcomes are ‘downstream’ from the health ones. Maybe different people are assuming that something else is going on — that the health and social outcomes are somehow independent, or that you just can’t measure the health outcomes as easily as the social ones, which seems backwards to me. (To me this was the missing gap in the IPA blog response to GiveWell’s criticism as well.)

So continuing to give so much attention to this study, even if it’s critical, misses what I took to be the biggest takeaway from that review — there have been a bunch of studies that showed only small effects or none at all. They were looking at health outcomes, yes, but those aren’t unrelated to the long-term development, social, and economic effects. You [GiveWell] try to get at the external validity of this study by looking for different size effects in areas with different prevalence, which is good but limited. Ultimately, if you consider all of the studies that looked at various outcomes, I think the most plausible explanation for how you could get huge (social) effects in the Miguel Kremer study while seeing little to no (health) effects in the others is not that the other studies just didn’t measure the social effects, but that the Miguel Kremer study’s external validity is questionable because of its unique study population.

(Emphasis added throughout)

Someone should study this: Addis housing edition

Attention development economists and any other researchers who have an interest in urban or housing policy in low-income countries: My office in Addis has about 25 folks working in it, and we have a daily lunch pool where we pay in 400 birr a month (about 22 USD) to cover costs and all get to eat Ethiopian food for lunch every day. It's been a great way to get to know my coworkers -- my work is often more solitary: editing, writing, and analyzing data -- and an even better way to learn about a whole variety of issues in Ethiopia.

The conversation is typically in Amharic and mine is quite limited, so I'm lucky if I can figure out the topic being discussed.  [I usually know if they're talking about work because so many NGO-speak words aren't translated, for example: "amharic amharic amharic Health Systems Strengthening amharic amharic..."] But folks will of course translate things as needed.  One observation is that certain topics affect their daily lives a lot, and thus come up over and over again at lunch.

One subject that has come up repeatedly is housing. Middle class folks in Addis Ababa feel the housing shortage very acutely. Based on our conversations it seems the major limitation is in getting credit to buy or build a house.

The biggest source of good housing so far has been government-constructed condominiums, for which you pay a certain (I'm not sure how much) percentage down and then make payments over the years. (The government will soon launch a new "40/60 scheme" to which many folks are looking forward, in which anyone who can make a 40% down payment on a house will get a government mortgage for the remaining 60%.)

When my coworkers first mentioned that the government will offer the next round of condominiums by a public lottery, my thought was "that will solve someone's identification problem!" A large number of people -- many thousands -- have registered for the government lottery. I believe you have to meet a certain wealth or income threshold (i.e., be able to make the down payment), but after that condo eligibility will be determined randomly. I think that -- especially if someone organizes the study prior to the lottery -- this could yield very useful results on the impact of urban housing policy.

How (and how much) do individuals and families benefit from access to better housing? Are there changes in earnings, savings, investments? Health outcomes? Children's health and educational outcomes? How does it affect political attitudes or other life choices? It could also be an opportunity to study migration between different neighborhoods, amongst many other things.

A Google Scholar search for Ethiopia housing lottery turns up several mentions, but (in my very quick read) no evaluations taking advantage of the randomization. (I can't access this recent article in an engineering journal, but from the abstract assume that it's talking about a different kind of evaluation.) So, someone have at it? It's just not that often that large public policy schemes are randomized.

"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.

Fugue

It took the World Bank 20 years to set up an evaluation outfit -- a new paper by Michele Alacevich tells the story of how that came to pass. It's a story about, amongst other things, the tension between academia and programs, between context-specific knowledge and generalizable lessons. The abstract:

Since its birth in 1944, the World Bank has had a strong focus on development projects. Yet, it did not have a project evaluation unit until the early 1970s. An early attempt to conceptualize project appraisal had been made in the 1960s by Albert Hirschman, whose undertaking raised high expectations at the Bank. Hirschman’s conclusions—published first in internal Bank reports and then, as a book in 1967—disappointed many at the Bank, primarily because they found it impractical. Hirschman wanted to offer the Bank a new vision by transforming the Bank’s approach to project design, project management and project appraisal. What the Bank expected from Hirschman, however, was not a revolution but an examination of the Bank’s projects and advice on how to make project design and management more measurable, controllable, and suitable for replication. The history of this failed collaboration provides useful insights on the unstable equilibrium between operations and evaluation within the Bank. In addition, it shows that the Bank actively participated in the development economics debates of the 1960s. This should be of interest for development economists today who reflect on the future of their discipline emphasizing the need for a non-dogmatic approach to development. It should also be of interest for the Bank itself, which is stressing the importance of evaluation for effective development policies. The history of the practice of development economics, using archival material, can bring new perspectives and help better understand the evolution of this discipline.

And this from the introduction:

Furthermore, the Bank all but ignored the final outcome of his project, the 1967 book, and especially disliked its first chapter.... In particular, Hirschman’s insistence on uncertainty as a structural element in the decision-making process did not fit in well with the operational drive of Bank economists and engineers.

Why'd they ignore it?

The Bank, Hirschman wrote, should avoid the “air of pat certainty” that emanated from project prospects and instead expose the uncertainties underlying them, exploring the whole range of possible outcomes. Moreover, the Bank should take into account the distributional and, more generally, the social and political effects of its lending.

It seems that one of the primary lessons of studying development economics is that many if not most of the biggest arguments you hear today already took place a generation ago. As with fashion, trends come and go, and ultimately come again. The arguments weren't necessarily solved, they were just pushed aside when something newer and shinier came along. Even the argument against bold centrally-planned strategies -- and in favor of facing up to the inherent uncertainty of complex systems -- has been made before. It failed to catch on, for reasons of politics and personality. Ultimately the systems in place may not want to hear results that downplay their importance and potency the grand scheme of things. On that note it seems that if history doesn't exactly repeat itself, it will at least continue to have some strong echoes of past debates.

Alacevich's paper is free to download here. H/t to Andres Marroquin, who reads and shares a ridiculous number of interesting things.

On efficiency

A friend of mine who is working in public health in a South American country writes great email updates about the specifics of her work, which often end up illustrating something universal. I thought this note -- about the latest delays in accomplishing a relatively simple task that has taken weeks when it should have taken hours, or maybe half a day at most -- nicely illustrates how much time can be wasted through the accumulation of minor inconveniences or annoyances. No single act is backed by poor intentions, but the final effect is that no one can get much done. Shared with permission:

Today’s visit to the Municipality of [...] was particularly silly.

It went like this: I arrived at 10:45am and went to the Budget Office. The Budget Office sent me to Provisions Office, which sent me back to Budget Office, which sent me backed to Provisions Office accompanied by a secretary.

The Provisions Office sent us to the Head Administration Office, which sent us to a different Administration office on a different floor, which sent us back down to the Provisions Office, which sent us back up to the Administration Office, which sent us back down to the Provisions Office. This all took an hour.

Then, I waited in the Provisions Office while they looked for the resolution that was supposed to be attached to my project, and they all blamed a different secretary in the office for why they couldn’t find it. After an hour of waiting in the Provisions Office, I got tired and hungry and had to pee, so I made up an excuse for why I had to leave and I asked when I should come back and where I should go.

They told me to come back in two days, which is what they always tell me. So, I’ll go back in two days.