My Little Buttercup, Or what happened when I visited a community health center near Bo

I wanted to see a community health center, where clinicians might have seen suspected Ebola cases three years ago. So, I asked my driver, Idrissa, whether he could ask some of his local contacts about the location of the health center in Gondama. I hadn’t been to Gondama since 2003. It wasn’t too difficult to get to, we knew. I had, in fact, seen a sign for the place when we were driving elsewhere. So, on Wednesday morning, we drove over a weather pitted road to the health center. When we arrived, a guard opened the gate to the modest facility. At least a half dozen men and a few women were in the waiting area.

Odd, I thought. My experience was that women tended to go to health centers, but not a lot of men – not because men don’t get sick or hate health centers, but because women and children are often the target of community health interventions (but that is another discussion for another day).

Two women greeted me, and nodding toward the group of men and women in the waiting area, told me that the community health workers (CHWs, they called them) were all there, ready.

Odd, I thought. Impolitic as it was to think or say, I didn’t really care about CHWs. Not today. But I did ask whether there were any female CHWs because, judging from the small group gathered, there didn’t appear to be any. “Yes, there are women there,” they said almost indignantly. I corrected myself and asked sheepishly, “But are there more men than women, or about the same number of both?” They laughed – more like harrumphed – and told me, “Well, it’s not 50-50,” a reference not to an actual ratio, but the way gender parity was often discussed colloquially in Sierra Leone’s development industry.

I followed the women – I’ll call them Amie and Fati – into an office where we sat at a table. The small room was crowded with furniture, and the walls were covered, predictably, with posters from the ministry of health related to women and children’s health. They began to interrogate me about what I wanted to know, and asked me if I wanted to look at their rosters, and when I would be talking to the CHWs who had gathered to meet me. The CHWs had been waiting and were becoming impatient.

Then it occurred to me: they thought I was someone else! (The reference in the title of this post is to that mistaken identity scene from Three Amigos, if you hadn’t caught it). I told them, “I’m not here to meet with CHWs.” I told them that I was just around and happened to come to Gondama. I didn’t have any specific questions, really, but did they happen to see Ebola three years ago? Yes, but they referred them to the district hospital. Having been a consultant once upon a time, I mentioned that unlike a consultant, I was not interested in extracting information from their registers, their CHWs or them. I simply wanted to observe. Their eyes widened. But surely, I was from an NGO. Nope, I wasn’t. This kind of admission – that you had no NGO affiliation or specific agenda besides ‘observing’ — can make you seem unserious if not untrustworthy. Everyone has a mission, whether they admit to it or not.

The facility’s in-charge, as in most of the places I visited during this short, unannounced trip, had been called to Freetown for a meeting. Whatever his shortcomings, among them was that did not give them enough information about who would be visiting, their purpose, or even the time these inquiring strangers would be arriving. I suspected that their confession was a bit of shade towards their co-worker, but it was also some shade towards the process itself: people were coming all the time to gather information; strangers like me were interchangeable with each other. The logos on our white Land Cruisers could be swapped and they would be none the wiser; the stranger could be from Boston or Washington or London, Johannesburg or Nairobi. The source of the information to be extracted was a circle of gathered CHWs or maternal registers, or immunization charts mounted on the walls or…

“Won’t you come and look at our labor and delivery area?” asked Amie. Inside the maternity ward were a couple of midwives who asked me if I too was a midwife. I told them no, but I’m a mother of two. (No comparison, though. Their work can be rough). There were four or five padded tables separated by curtains and fitted with stirrups. In a separate room, there were a few beds for new mothers who would, after their deliveries, be discharged after 72 hours. On a wall near the entrance, I read the instructions about when to deliver oxytocin, and briefly recounted the induced delivery of my daughter five years ago. Then I told them about the worried look on my obstetrician’s face when she couldn’t stop the bleeding during my second delivery. I mentioned how my son’s heart rate began to decline rapidly, how I strained to block out any semblance of panic by pushing. “Eeeeeehhh,” they said almost in unison, sucking their teeth at the very real trauma of childbirth. But the boy was healthy and strong. I would have panicked for nothing. I reached for my phone. “Yu wan si mi pikin dem?” Yes, sure, they said. I showed them pictures of my babies. Then I gave them my card and said I’d be going so they could prepare for the real guest.

They wished me luck on my quest — whatever it was. I wished for them a not-too-much longer wait for the stranger who wanted to meet with the CHWs.

Falling in love: the reductive seduction of social entrepreneurship

Or is it the seductive reduction of social entrepreneurship? I’ve seen Courtney Martin’s essay circulating for the past few days; I read it amongst a slew of development articles popping up in my Twitter timeline. The point of the essay appears to be: don’t go to work on development/social change projects in other countries simply because it sounds like their problems are more interesting and easier to solve than the ones in your own backyard. She provides this (and several other nuggets of) pithy advice for aspiring social entrepreneurs and aid types:

  • … don’t go because you’ve fallen in love with solvability. Go because you’ve fallen in love with complexity.
  • Don’t go because you want to do something virtuous. Go because you want to do something difficult.
  • Don’t go because you want to talk. Go because you want to listen.

Perhaps by design, the essay manages to reduce social entrepreneurship to its core virtues and values: a story featuring “you” as an agent of change, who, above all, travels (“go”), falls in love (“is passionate”), acts (“does something”), talks (“engages in conversations”) and solves (“complex”) problems.

It seems that the underlying premise is that if you expect the work to be difficult and complex and you at least act like you don’t have the answers, then … the work you set out to do will be successful? In some ways, it’s circular logic. Why go if you don’t have a “project” or business in mind? What are you listening to (and to whom), if not just for a place to slot in your idea? Why assume that there’s something for YOU to do and to FALL IN LOVE with?

There’s a lot more to say about the essay, including the Tostan case study (which raises questions of temporality vis-a-vis development-type projects and whiteness), the notion of the “unexotic” and her insistence that “reduction” isn’t malicious, but there is other writing to be done.

On Ebola and the pathological movements of Others

This morning, I woke up to two emails about the most recent NYT article about the Ebola outbreak in West Africa. Having worked in Sierra Leone on a range of health issues, I have been a recipient of these kinds of messages at least a few times a week. I’ll just comment on this article because it best articulates a number of trends that I am seeing in these articles.

From Guinea, Adam Nossiter writes:

Eight youths, some armed with slingshots and machetes, stood warily alongside a rutted dirt road at an opening in the high reeds, the path to the village of Kolo Bengou. The deadly Ebola virus is believed to have infected several people in the village, and the youths were blocking the path to prevent health workers from entering.

“We don’t want any visitors,” said their leader, Faya Iroundouno, 17, president of Kolo Bengou’s youth league. “We don’t want any contact with anyone.” The others nodded in agreement and fiddled with their slingshots.

Singling out the international aid group Doctors Without Borders, Mr. Iroundouno continued, “Wherever those people have passed, the communities have been hit by illness.”

What I find intriguing about this piece is that it’s one of the first to make explicit people’s mistrust of international health workers and their motivations. Implicit is, as Susan Shepler notes, a related mistrust of government officials and the perceived competence of government officials to manage an epidemic, have shaped local responses to this outbreak. Add to this that hospitals are widely perceived to be a place where people become sick or die — not simply in West Africa, but elsewhere, too — and we’ve got ourselves some moral panic. (It bears repeating, too, that Ebola was previously unseen in the region and looks like a lot of other endemic diseases in its early stages. Where I previously worked,  Lassa Fever, a hemorrhagic fever with which many Sierra Leoneans are familiar, was also endemic, raising questions for me about whether they used those lessons to address Ebola.)

So, back to the NYT. Young men are trying to bar MSF from their village. Yet, in the paragraph following this vivid description, the analysis falls back on pathologizing the movements of West Africans:

Health officials say the epidemic is out of control, moving back and forth across the porous borders of Guinea and neighboring Sierra Leone and Liberia — often on the backs of the cheap motorcycles that ply the roads of this region of green hills and dense forest — infiltrating the lively open-air markets, overwhelming weak health facilities and decimating villages.

In short, foreigners should move and have unfettered access to ‘Africa’, but these same (literally pathological) movements of foreigners — certainly not all white and Western, but at least symbolically so — are pushed to the background, while the usual movements of West Africans are pathologized. They must stay in their rightful place.

This is not to say that epidemics aren’t traveling “on the backs of cheap motorcycles,” but these young men suspect, as many others in the region do, that (1) the disease may also be traveling with the foreign health workers who move fairly easily across international borders and who are at greatest risk for contracting the disease; (2) that there was a slow and inadequate government response upon initial rumors of the outbreak; and (3) the arrival of Ebola to West Africa is not a simple matter of chance, porous West African borders, ignorance and ‘local traditions’, but one embedded in a range of biological, political, economic and cultural arrangements that have put entire communities at risk. These at-risk communities are having a hard time building trust with people who have failed to control Ebola.

Blurred lines: development, human rights, humanitarianism

Last week, we read Bornstein and Redfield’s introductory chapter to Forces of Compassion. In it, the authors outline a distinction among development, human rights, and humanitarianism. The temporal orientation, disciplinary foci, and the professions associated with each of these forms of social action seem to distinguish them from each other. The authors state, for example, that development is associated with economics, livelihoods and poverty, and are progressive/future-oriented, while human rights organizations are concerned with law, and correcting past wrongs. Humanitarianism is medical and preoccupied with the present, the ‘right now.’ They draw this distinction, I think, because there’s a group of anthropologists who have lumped the work of improving and ‘saving’ lives under ‘humanitarianism’ — the suggestion here being that humanitarianism’s particularity is rooted in a particular conception of ‘humanity’ and ‘life’ and an ethos or structure of feeling, rather than professional and bureaucratic categories. The authors note that their three-pronged schematic is crude, but I think it is telling that they need to provide this schematic at all. Again, I think it lies in humanitarian and development professionals’ clarity about what distinguishes them from each other, and the kind of ethics and professional practice these different kinds of intervention entail. Yet the institutions engaged in these forms of social action not only perform many of these functions at once, but also find themselves using multiple frames simultaneously to justify and continue their work.

As a kind of thought exercise, I went to several international non-governmental organization (iNGO) websites and looked at the short program publicity reports to see how well Bornstein and Redfield’s categories hold up in ‘practice’ — or at least in the routine NGO practice of describing projects for a general audience. I cut and paste these excerpts into a quiz and asked students to identify whether they described humanitarianism, development or human rights programs, as defined by Bornstein and Redfield. Although I was sure to pull excerpts that generally fit the descriptions provided by the authors, students still had some trouble placing the quotes into categories: could the participatory health program that held health facility managers accountable be considered a human rights  (on the issues of participation and rights-oriented language) and a humanitarian (for its medical orientation) program? Of course, the crude association of categories of intervention with professions and disciplines was perhaps less useful than the more analytical move of highlighting the temporal and ideological orientations that we associate with these approaches.

To drive the point home that these distinctions are quite blurred in practice — and manifest in different framing of social problems and, therefore, programs — I asked students to look at the websites of five different organizations (two human rights iNGOs, two development/relief iNGOs and a UN agency) and see how each organization addresses water issues. Of course, many of the largest iNGOs, like CARE or Oxfam, which are firmly situated in all three traditions, describe the problem in multiple ways; they have ‘cornered the market,’ so to speak. On CARE’s water website, for example, they use the language of emergency and crisis; that of long-term investment; and of public health and rights.

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A search for ‘water’ on two human rights websites, Human Rights Watch and Physicians for Human Rights, framed the issue much differently. In addition to suggesting that access to water was a human right, most of their reports concerned water access issues in terms of violations: police crackdowns on water access protesters; shaming mining companies that polluted water sources or displaced people from clean water; disease outbreaks due to poor prison conditions, etc.