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Monday, January 31, 2011

Pay the Poor

The Bangladeshi city of Chittagong has come up with an interesting way of getting rid of beggars: Paying them.  Read the full article from the BBC here.

Global Health/Development Links

Two great global health/development related pieces I came across today:
  1. Marginal Revolution has an awesome graph of income inequality across and within countries. It's somewhat confusing at first but read Tabarrok's explanation below. The take-home message: the poorest 5% of Americans are among the richest 30% of all people in the world. This is pertinent to my debate with Andrew over the relevance of inequality - I'm still not sure inequality matters per se but it's clearly incredibly motivating; the world is simply not fair and that is not okay.
  2. The NYT on the failure of Google.Org to change the world of philanthropy. The article highlights what I see as two factors that make non-profit work so hard: the lack of a simple metric for success (private firms can just look at profitability) and the bitter conflicts that arise because employees actually care passionately about what they're doing instead of working for a paycheck.

Aid Watch vs. The Girl Effect

The generally excellent and always interesting Aid Watch has another post today criticizing the Girl Effect. Their general point, which both their regular authors and guest contributors have tackled repeatedly, is that the Girl Effect treats women as means rather than ends to development. But bringing the focus to helping women seems like a good thing, and I'm not sure we should be so quick to dismiss the use of evidence-driven aid, even if it comes off as a little cynical.

I've also come to expect a little more credulity from the aid watchers. After all, Bill Easterly has played a major role in the movement toward looking skeptically at development assistance, and his insistence on considering people's incentives definitely shaped my view of how we should go about helping the poor. The quotes from Esplen should be seen in that light: with a shift away from rights and toward measurable outcomes, groups like hers stand to lose funding and status. One of the key lessons I've taken away from working with nonprofits is that not only do incentives & money matter, they often matter even more because people legitimately care about the outcomes.

In the interest of full disclosure (and to hold myself to the same standard I expect of Aid Watch) I am generally very skeptical of rights-based advocacy in the developing world; rights, especially expanded, 2nd- and 3rd-generation rights, are pretty irrelevant when governments are non-functional and people are on the very verge of subsistence.

Friday, January 28, 2011

Can Satire Be True?

From our good friends at The Onion

PARIS—At a press conference Tuesday, the World Heritage Committee officially recognized the Gap Between Rich and Poor as the "Eighth Wonder of the World," describing the global wealth divide as the "most colossal and enduring of mankind's creations."

Read the full article here.


While an undergraduate, I used to volunteer with an adult literacy program at a nearby men’s homeless shelter. The weekly “lesson” topic was established by the shelter staff, and the student volunteers would prepare materials accordingly. These followed a Freireian methodology, in that the men explored themes of interest to their own daily lives, and we, the “instructors” served mainly as facilitators for the discussion or interspersed reading/writing exercises.

Topics were often general, but lead into unexpected, yet illuminating discussions. For example, one week’s topic was, “Music.” We played Johnny Cash’s rendition of “A Boy Named Sue,” (one of Shel Silverstein’s darker works). One man commented that the opening lyrics resonated with his own personal experience living with an alcoholic father. When we asked the group if anyone else shared this experience, every single had went up. It was a living, breathing sociology class.

The most uncomfortable topic I was ever tasked with was: Motivation. Motivation is a loaded topic, especially as a class facilitated by privileged college students with a group of homeless men. I almost backed out. The men however, loved it. What surprised me was how incredibly positive they were. Motivation and strength derived from religious faith was a huge theme. In fact, in the entire group, there was one man who gave any hints at negativity, or expressed challenges to motivation. He had just lost his job as an electrician, and had three kids at home. He voiced his frustrations with his current job search. The other men responded in a positive—though perhaps naively so—fashion. One man exclaimed, “That’s why you need to work for yourself! Be your own boss [so that you don’t have to worry about getting fired],” to which another man responded “Right! You just need to get motivated—write letters to the government in Washington, they have all this money they will just give you to start a business. You just have to be motivated and write them.”

Meanwhile, everything in my academic courses (in sociology, critical theory and constructivism) were screaming out: from the internalization of a systemic failure as an individual problem of motivation, to differential knowledge of how political and economic networks are structured and accessed.

The men had very high expectations of themselves and their social systems. This may serve as a source of motivation initially, but it is unlikely to be sustained it if these expectations aren’t met. Similarly, in my current work with human resources for health, while many health workers enter motivated by a sense of “professional conscience,” or desire to better their communities, many become de-motivated when their efforts are continuously defeated by larger, systemic issues. For example, chronic medical supply shortages, or lack of supportive supervision by superiors at referral levels.

Similarly, Richard Levins writes on our role as “radical health workers”:
“ …We are also workers. We are hired to create and apply knowledge within the constraints set by our employers. But we are a special kind of worker in that our labor is not completely alienated from us: we are really concerned with the product of our labor, with what it does in the world, unlike the employees in an ammunitions factory who do not seek out that job for the joy of helping to kill people. As workers, a major concern is to keep our jobs and receive reasonable compensation and benefits. But as intellectuals we want our work to be meaningful and effective. We are terribly frustrated when we lack the resources to do what obviously needs to be done, when class size or number of patients to care for guarantees that we cannot do what we entered the profession to do and when our best ideas are not fundable or not even mentionable, when our activism is condemned as unprofessional, when our tasks are constrained by wrong or narrow theories, when we may contribute to deep studies of the problem but the reports end in banal recommendations such as ‘we should pay more attention to questions of equity’ or the almost inevitable ‘more research is needed.’”
As several recent Methodlogical posts have discussed, often what motivates us—to vote, or to serve—is complex, and far from rational. It seems to me that motivation is as much a product of our social systems as it is of our individual predilections and personal sense of fulfillment. I’m interested in your own experiences with motivation, and how you think we can change our systems—and the incentives inherent to them.

Thursday, January 27, 2011

Market-Based Solutions to International Development?

If you walk around the Harvard Business School, you can't go more than 2 days without hearing certain buzz words: "market-based solutions," "base of the pyramid business models," and "social entrepreneurship" to name a few. The common theme is integrating private sector approaches to international development and poverty alleviation efforts. The concepts are certainly fascinating, and even I find myself intrigued by conversations about venture philanthropy firms, private equity firms working in emerging markets, and cool business ideas that serve the poor. We can talk the talk, but what sort of companies out there have really walked the walk? Here are 3.

1. LifeStraw. Designed by Swiss company Vestergaard Frandsen, LifeStraw makes dirty water clean. It is a 25 cm long, 29 mm diameter plastic straw that contains of point-of-use water filter in its base. The manufacturers have priced it at US$2. LifeStraw removes 99.999% of waterborne bacteria, 99.99% of viruses, and 99.9% of parasites. It can be used for approximately 1 year (700 liters) before the filter must be replaced. As a result of killing disease-causing microorganisms, it can prevent diarrhea, dysentery, typhoid, and cholera. LifeStraw is a for-profit product, for sale both directly to consumers but also many non-profits have worked with LifeStraw to purchase and distribute it in humanitarian crises (most recently the 2010 Haitian earthquake and the 2010 Pakistan floods).


2. Banana Leaf Sanitary Pads. Elizabeth Scharpf, founder and CEO of Sustainable Health Enterprises (S.H.E.), is working to address a major underlying cause of female absenteeism in school and in the workplace: mensutruation. The alarmingly high rates of absenteeism in schools and in the workplace that resulted from women reluctant to come during their menstrual periods is a reality in many developing countries. The #1 reason? Sanitary pads are too expensive. In order to create a more affordable option, S.H.E. now works with local Rwandan women to manufacture and distribute affordable, quality, and eco-friendly sanitary pads made from banana tree fibers. Since 2009, S.H.E has also trained 5,000 Rwandan women to set up their own sanitary napkin micro-enterprises. Scharpf has become part of the movement that Nicholas Kristof calls the D.I.Y. Foreign Aid Revolution.

S.H.E. Sanitary Pads Being Manufactured in Rwanda

3. ClickDiagnostics. One of several companies competing in the telemedicine space, ClickDiagnostics is a software program that allows for community health workers to use a hand-held interface to do a quick differential diagnosis and send photographs to remote physicians. ClickDiagnostics has experimented with several interfaces/platforms for the software, ranging from smartphone apps to more basic flip phone mobile technology. The for-profit company sells their technology to Ministries of Health, NGOs (including BRAC), universities, and hospitals for use in Bangladesh, Botswana, Kenya, Uganda, and Ghana. If anyone knows more about the telemedicine market, I'd love to learn more about how ClickDiagnostics measures up to its competitors. Maybe the MD's out there can also shed some light on the scale-ability (or lack of scale-ability) of telemedicine.

Community Health Worker Using ClickDiagnostics Mobile App

Would love for others to add to my list of favorites, as well. For those interested in exploring social entrepreneurship further, check out the upcoming Harvard Social Enterprise Conference, March 5-6, 2011.

Wednesday, January 26, 2011

The Other Middle Class

Foreign aid is a tricky thing. While it can often be a shining example of humanitarianism and compassion, it can also smack of real politik; who gives to whom, how much, and when is often more a reflection of geopolitical strategy than of objective need. Further, various development types (notably William Easterly) will tell you that aid doesn’t do a whole lot of good for its recipients. Nonetheless, most of us would broadly agree on the importance of development assistance and humanitarian aid. But who should pay for it?

For the first time in history, more poor people live in middle-income countries than in poor countries. This was not the case when the World Bank was founded nor when the Gates Foundation was founded.  Think more around the time MethodLogical was founded. While there is no perfect definition for poor or rich countries (or those in between), the World Bank takes a stab at it. What it and others have been finding is that countries are rapidly industrializing and ascending from the “poor” category to the "middle-income" one, resulting in this demographic shift.

It should be noted that this trend may be somewhat exaggerated. Given that China and India account for about a third of the world’s population, any demographic shift that includes both of them is likely to have a significant global impact. And indeed, both China and India have recently graduated to middle-income status, bringing loads of poor citizens along with them (as well as a hefty amount of incoming aid dollars). Disproportionately large though they may be, China and India are not alone.  27 countries have made the shift since 2000. And by and large, this is a good thing.

The problem is—as anyone who has traveled to India or China or Brazil could tell you—a surging economy doesn’t erase all poverty. National growth may be good for most people (including the poor), but it’s no silver bullet. But as these countries add to their coffers, is it still the responsibility of wealthy nations to give them aid? Or is it time for these blue-collar countries to take care of their own?

Is she doing her part to aid her countrymen?

Firstly, we must ask if they are fully able to address their own needs. China has the money to spend a ton on its military, but if redirected, would it be enough to radically help the hundreds of millions of poor people inside its borders? If so, is it still the responsibility of developed nations to step in if a middle-income country is using its wealth irresponsibly? But what about Botswana, which spends quite a bit less on its military, but is still groaning under the weight of its HIV epidemic and widespread unemployment?

We also have to look at inequality. Though maligned, the Gini index is the best estimate of income inequality in a country. China and India fall in the middle third of nations, though the top third features quite a few middle-income countries. Addressing inequality has been a vexing question for all countries, rich and poor alike; some advocate redistribution while others prefer to let the free market do the heavy lifting. Regardless of method, it doesn’t hurt to have good governance, human capital, and an efficient bureaucracy in place. Capacity to address inequality does not materialize just because a country is manufacturing and/or exporting a lot. Perhaps this is an area where some newly minted middle-income countries suffer, as economic gains may outpace a nation’s ability to train the personnel necessary. It is reasonable to expect this capacity to lag behind economic growth (especially if the growth is a result of private sector success and takes time to translate into revenue for the state), and international assistance may be a reasonable bridge in this period.

I remain pretty agnostic on most of this, mostly for lack of definitive data. Perhaps more critical is the issue of how accurate the World Bank’s categorizations are. MethodLogical contributor Jason Kerwin has argued that these economic measures are far from perfect, while MethodLogical contributor Jason Hopper has mused on the usefulness of other measures, such as the Human Development Index or the Multidimensional Poverty Index. But as countries (if not individuals) acquire wealth, the dynamic of developed-developing countries will continue to evolve. The question of how best to aid the poor remains the same, but perhaps our methods must evolve as well.

Monday, January 24, 2011

I've Said It Before and I'll Say It Again: Democracy Doesn't Work

Steve Levitt recently raised the ire of Andrew Gelman, among others, by insinuating that it's not rational to vote. The basic argument, which Levitt really doesn't lay out too well, is that if voters acted in their narrow (monetary) self-interest they wouldn't vote, because the likelihood of altering the results of an election is incredibly low. Gelman's responses is that voting can be completely rational if you place some value on benefits to other people, that is if you're altruistic. If that's the case then the value of changing the results of an election is astronomical, so even if the chances are low it's a good bet. This story doesn't sit right with me: ask people why they vote and very few can quantify their odds of altering an election outcome. That just doesn't seem to be how people think about the problem. My friend Dan Hirschman pointed out that Gelman's argument is really more of an "existence proof" - it shows that it is possible for voting to be rational, for certain preferences, and it's valuable even if it's not the true reason people vote.
But the real reason people vote is really important, because it helps us understand what they vote for. The "rational voter" models that Levitt was implicitly attacking tend to assume that voters, or groups of voters, are voting for whatever benefits them most personally. That certainly isn't the case: what would benefit people most personally (that is, ignoring altruism) is to not vote in the first place. People are necessarily thinking about other factors than their own narrow self-interest. It's possible this means looking at benefits to others; a simpler story would be that people vote because they find it enjoyable (Gelman said this applies to himself in a response to one of my comments) or out of a sense of civic duty. Whatever the real story, the implications of this for election results are profound, and tend to be somewhat depressing; Bryan Caplan goes through them in detail in The Myth of the Rational Voter, which I can't recommend highly enough for people interested in policy and voting. To take one stark example from the book, a strong majority of Americans realize they personally benefit from trade liberalization, so rational voter models would predict support for freer trade. But many of those same people believe that trade is bad for society as a whole, and so they vote against it.
The upshot is that democracies, even well-designed ones, pick policies that are systematically worse than we might otherwise hope. And even if voters are rational and self-interested, getting democracy to work well takes a lot of work. As I pointed out in a comment on Jason Hopper's post last week, I think an emphasis on democracy as a development goal doesn't do people a whole lot of good. Part of this is practical: we tend to think of democracy as simply "holding votes and the majority rules" but in fact you need a lot of physical and institutional infrastructure to make democracy actually work; furthermore, as Hopper pointed out there are a lot of variations on democratic systems and I think which one works is very context-specific. But it's also a basic feature of democracy itself: horrible policies can be extremely popular. It's easy to think of extreme examples - Robert Mugabe was legitimately elected many times even as he devastated Zimbabwe. I'm aware that this sounds like I'm saying that we should ignore people's desires, but really I'm arguing for the opposite. Democracy doesn't do a very good job at listening to what people want and need. It's a valuable tool - it does do a good job of preventing the worst abuses of bad governments - but when we're talking about what to focus on in development I think it should be closer to #20 on the priority list than #1.

Friday, January 21, 2011

Excuses, excuses

Andrew will not be posting today because he is recovering from malaria.

Did you know you could get malaria even if you're on prophylaxis?

Don't worry- he's recovering nicely, so please enjoy this article.

Please note, exposing our contributors to lethal pathogens will NOT become a regular feature on MethodLogical.

Wednesday, January 19, 2011

Is Democracy a Universal Ideal?

I’ve been spending a fair bit of time reading up on civil society, democracy, and politics more generally in a cross-cultural perspective. Being an anthropologist, but also someone committed to the idea of social justice, I am left in a bit of a dilemma: Do our ideals of democracy apply universally? How far and in what ways is cultural relativism relevant when discussing topics like democracy?

Certainly in both American foreign policy and in the social sciences the term tends to get used as a universal ideal. There’s a certain evangelical ring in a lot of the official policy discourse about spreading “democracy and freedom” around the world. In the social sciences, some writers tend to reduce democracy to a few institutions or a method of decision making such as elections—a tradition that grew out of Joseph Schumpeter’s writings. Others, like Robert Dahl, have defined ideals first and gone out to test to see if certain institutions realizes these ideals, but with little sensitivity to the fact that the ideals chosen may be influenced the scholars own social and cultural background.

A book I am finding very thought provoking on this topic is Frederic Shaffer’s Democracy in Translation. Political Scientist by training, Schafer uses linguistic and ethnographic methods to try to understand how native Wolof speakers in Senegal speak and think about democracy. Schafer then compares these ideas to elite discourses in Senegal, to American understandings of democracy, and to academic theories of democracy. His focus is on understanding Wolof perceptions of democracy in their own terms and the variety of ideals that may guide democratic institutions (8). What he finds is that both popular ideals and academic theories of democracy differ substantially from understandings of democracy on the ground in Senegal.

Demokaraasi, the Wolof term, although etymologically related to the term “democracy” focuses on consensus, even handedness, and solidarity (84). In other words, a common Senegalese conception of democracy does not focus on individual freedom to decide who to vote for, breadth of participation, keeping elected officials accountable, or the creation of at least an ostensibly equal political sphere. Instead, maintaining community solidarity and networks of reciprocity; a sense of fair treatment from those higher in the political hierarchy; and general amicable agreement are considered more important. The implications of this difference can be profound. For example, people in Senegal often choose their vote so as to maintain smooth social functioning rather than for a particular candidates platform (98). Even vote-buying can be a completely ethical form of exchange if it is perceived to be part of a properly reciprocal relationship (98).

However, Schaffer does not argue that democracy is untranslatable or that some cultures simply cannot conceive of democracy. Rather he argues that: “Democracy,”…is unique in the particular combination of its features; but each individual feature may still have analogues in other languages and cultures” (145). The ideals that come to be associate with democracy in any particular case are a mix of more familiar, internationally recognizable forms, and local concerns and culture. Which ideals become important and how they shape politics, however, and mean every case deserves its own attention. Schaffer’s approach has the advantage of not reducing democracy to simply elections nor relying on the uncritical use of measurements that rely on culturally specific political ideals. 

However, the book never resolves the issue of whether these cultural forms are sometimes a type of false consciousness, or ideology, or veneer that hide exploitative or authoritarian realities. What are your experiences with democracy or discussing democracy with other people? Do you think democracy is universal or culturally relative?

Tuesday, January 18, 2011

Tackling Non-Communicable Diseases in 2011

2011 is going to be a turning point for making non-communicable diseases (NCDs) prevention/control a priority on the global agenda. The UN Summit on Non-Communicable Diseases will take place on September 19-20th, 2011 in New York, and will bring together UN Member States along with representation from the civil society to hammer out a global plan to respond to the growing threat of NCDs.

The major NCDs (cardiovascular diseases, diabetes, chronic respiratory diseases, major cancers) are the leading cause of mortality world-wide. They account for 60% (35 million) of global deaths, with the major burden (80%) in low- and middle-income countries (LMIC), 26% of which are premature deaths (before the age of 60 years). As shown in the table below, the NCD burden (as % of total DALYs) is projected to be the leading sources of DALYs by 2030 (WHO, 2008). Thus, NCDs are also a threat to the economies and development of nations, and the progress of the Millenium Development Goals. Despite this sobering information, funding for NCDs has represented less than 3% of the global development assistance for health.

[WHO Global Burden of Disease: 2004 Update (2008)] 

Yet, all the statistics, evidence and good will won’t change the status quo without the political/social commitment and money, so a UN meeting is a major opportunity. The last UN Summit on a health issue was HIV/AIDS in 2001, which led to the establishment of the Global Fund and developed international efforts to address the disease.

However, the case of NCDs is a different beast, especially when it comes to creating consensus with the industries (tobacco, alcohol, and food/beverage). Apparently, the tobacco industry, which is considered part of the problem, was excluded from the World Economic Forum gathering in November 2010 to plan for the September 2011 UN Summit on NCDs. I am curious as to how the tobacco and alcohol industries will actually be tackled; tobacco will have to be invited to the table at some point for negotiations. On the other hand, major food and non-alcoholic beverage industries seem to be on board and have already made commitments to help consumers have balanced diet and healthy lifestyles (such as food marketing, nutrition labeling, creating ‘healthier’ products). Yet, this social responsibility seems superficial, since the ‘unhealthy’ products they make are still being sold (although banning candy or soda sales, for example, is pretty unrealistic; outside restriction in school and work environments). Moreover, the economies of countries may depend on the sales of these products (i.e. China and tobacco), so finding a compromise for NCD prevention with industry will not be simple. 

A major advocate from civil society is the NCD Alliance (coalition of major international NCD groups: International Diabetes Federation, World Heart Federation, Union for International Cancer Control, International Union Against Tuberculosis and Lung Disease), established in May 2009. In preparation for the meeting, the group has been conducting research, collaborating with governments, NGOs and businesses for coordinating planning, engaging the media and raising awareness. Their ‘asks’ for the UN Summit include: governments be accountable and measured on NCD plans, Framework Convention on Tobacco Control to be fully implemented, global commitment to prevent the preventable, globally agreed approaches to NCD treatment and care, resources to deliver NCD interventions, and NCDs in the MDG successor goals. The earlier referenced BMJ blog post by Richard Smith describes the WHO having similar priorities, and also emphasizing ensuring sustainable funding.

What I find promising are the goals to improve health systems at a primary care level (Alma Ata Declaration still going strong) and national capacities strengthening (including sustainable funding), which address the root structural and socioeconomic factors of poor health (pertaining to any condition). These changes no doubt take time, but maybe efforts will speed up now, since the nature of NCD prevention requires creating conducive environments for healthy living. This means pushing for primary prevention solutions of the shared risk factors (tobacco, unhealthy diet, physical inactivity and harmful alcohol use) of NCDs, and addressing access to essential medicines and proper health services for secondary and tertiary prevention. In this way, developing countries have the opportunity to learn from the epidemiologic transition (Omran, 2005of developed countries and apply the necessary interventions to at least blunt the rise of NCDs.  

(More references: This recent review article summarizes the elements needed for a context-specific national NCD policy. The Lancet also had a series in November 2010 regarding NCD intervention strategies.) 

To help the cause: The NCD Alliance has put together a summary on how to get involved. There’s also a dynamic web-based group of young professionals focused on chronic disease issues. 

Monday, January 17, 2011

For Profit/Non Profit Model

I was going to publish a post today on Muhammad Yunus' Op-Ed in the New York Times this weekend but I'm still trying to figure out my own opinion on a number of Yunus' points. Don't get me wrong, putting a cap of Cost of Funds + 15% on interest rates is pretty stupid. 1, we don't all live in Bangladesh where population density is so high that even microfinance operating costs are low. 2, this strikes me a bit like price-setting but without controlling the apparatus to force it to work anyways. With a cap on rates in areas it is expensive to operate, microcredit would simply dry up. There wouldn't be any private profit-making but only because there wouldn't be much/any microcredit activity.

But I think Yunus has a point on, at least partial, community ownership of microfinance institutions. And I think he also has a point with regards to the role NGOs once saw themselves in the financial lives of their borrowers and the role new for-profit MFIs see for themselves. With all of that said, I'm undecided on whether private, for profit funding for microfinance is a net good. And regulation has a decidedly mixed record in the sector. So I'm going to take a few more weeks to think about this all and try to post on it in 2 weeks.

In the meantime, a few questions I haven't thought about much but am curious about:
1. Why does Bangladesh have a significant number of big, multi-sectoral, and domestically created community based organizations whereas few African countries do? Or am I suffering from a selection bias in those orgs I know of? BRAC and Grameen come to mind quickly.
2. When will more South Asian NGOs and companies make big pushes into Africa and will they kill off less efficient, locally grown organizations/companies? Is this a good thing?
3. Will the Jets beat the Steelers next week?