Written on June 19, 2012:
Hey y’all,
Happy summer up there! Can’t believe it’s already time to say that. I don’t quite know what season it is here because the temperature is all over the place on a daily basis. I never know whether I’m going to be trying to keep warm by literally donning every layer I own (picture that FRIENDS episode where Joey puts on all of Chandler’s clothes... “Could I BE wearing any more clothes??”)... or sweating and carrying said layers around like a hobo.
When I went to Swaziland on a little vacation last month, it felt like real winter, not just Africa winter. Freezing my butt off in an English-speaking country and surrounded by fellow foreigners and ex-pats at a swanky music festival, I didn’t quite know where I was.
It’s always a bit disorienting going back and forth between Mabote and the quasi first world bubbles you can find in places like Maputo and the music festival in Swaziland. But this time was even stranger because before crossing the Swazi border, I spent a couple nights with friends at the apartment of an acquaintance in Maputo. This acquaintance is actually in charge of the international non-governmental organization (INGO for short) program that funds one of my associations.
To be honest, I felt a little uncomfortable staying at her apartment. I doubt my Mabote colleagues even know who she is, but I couldn’t help but wonder whether they would see me differently if they knew I was staying there. “Sheeh! Mana Julia, look at you, you’re a big deal!” I can hear them saying... in so many words. Or, never prone to let an opportunity slip by, “Juli-o, ask her to buy us a car so we can drive people to the hospital!”
I think one of the things that made me feel uneasy was grappling, in a very immediate way, with my first world privilege and power: the fact that I can get in doors that they would never have access to. When you’re in the habit of sitting on the ground under a tree, swatting flies with the mães (mothers, a.k.a. “my Mabote ladies” as I called them in my last post)... to suddenly find yourself at a dinner party eating chilli con carne with cheddar cheese and blondies for dessert next to their chefe’s chefe’s chefe (boss), it’s more than a little unsettling.
There were six guests at our little dinner party: three Peace Corps volunteers and three INGO staff members, one of whom was in town visiting from Washington, DC. We were all around the same age, all American, and among the six of us, it turns out we’d only gone to four different colleges. So we had a lot in common. As we were making conversation, the guy in town from DC remarked that he was thinking of getting out of international development work because he was disillusioned with it. He said something like, “I don’t know any other industry where you can fail 90% of the time and keep getting rewarded.”
My fellow volunteers and I – all of us placed with INGO-funded HIV/AIDS projects – exchanged knowing glances. Our frustrations with the mainstream INGO – or “international development” – industry is a common topic of conversation when we get together. A little later when it was just him and us three volunteers, I told him that a lot of us feel the same way, that we talk about it all the time. He laughed and said, “Yeah, but there sure are a lot of you who go to work for them afterward.” And, of course, he’s right.
So that got me thinking... why is that? Do we go in thinking we’re going to change the system from the inside, and then become part of it? Do we at some point lose site of what many of us see so clearly now: that something is terribly wrong here... and instead come to see only what we want to see?
The thing is, I can see how it could happen to me and people like me. Sure, I sit around ranting about the INGOs now, but I don’t want to sit under a tree swatting flies forever. In fact, as you could probably tell from my last post, sometimes I can’t wait to move on to bigger and better things. Things that my first world privilege allows me: like graduate school, for instance. And then after that, when life starts getting all serious and I’ve got student loans to repay, suddenly working for an INGO might start looking pretty good. “I lived in Mabote for two years,” I can see myself thinking. “I know how things really are, so better me than someone else... I could change things!”
But would I? Can one person really change the system? It’s a tall order...
Recently I was out in a tiny town called Gubo Gubo (best name ever, right?). I was with one of my associations’ activistas (home-based care providers) as she was visiting several of the patients she’s responsible for to monitor their adherence to their ARVs (AIDS medication) and just generally check on them. In theory, the activistas are supposed to be trained community-based health workers, able to provide a minimal level of counseling and basic care for those who aren’t sick enough to be in the hospital or who can’t get to/won’t go to the hospital.
In reality, all I’ve ever really seen the activistas do is monitor drug adherence and hospital visits by counting pills and checking the appointment cards patients receive at the hospital. And when people don’t show up to their appointments, the activistas are sometimes able to track them down and get them to go back. It’s not that that’s not adding at least some value, but it’s much less than what they’re supposedly doing on paper.
They don’t even have the medical kits they’re supposed to have (things like gloves, gauze and Tylenol). They do, at least, sometimes have condoms. But many of the activistas know very little about basic health topics. And some of them can’t speak or read Portuguese (supposedly a requirement to be an activista) so I don’t know how well they’re even able to monitor adherence and appointments, when the appointment cards and prescriptions are written in Portuguese.
Also in theory, the activistas are supposed to be in the field twice a week, but it’s always clear whenever I tag along, and when I try to make sense of their wonky data reporting sheets, that that isn’t happening. And for most of their patients, I’m not even sure what the activistas would have to do if they went that often – count pills more frequently? Remind them, again, of when their next appointment is?
The woman I was with in Gubo Gubo is, in my opinion, one of the best activistas. She had the idea of bringing her patients together into a kind of support group, so they could discuss common issues and concerns. So she was meeting with her group of three or four patients, counting their pills and checking their appointment cards, and asked them what problems they had. One man starts telling her how he has trouble taking his pills because when he swallows them they “don’t find anything (as in, food) in his stomach” so he often vomits them up.
ARVs are strong and shouldn’t be taken on an empty stomach, so it’s no wonder he vomits. And they also increase a person’s appetite, so it’s a double whammy: you need to take them with food and then they make you hungrier. So when you don’t have much food, it can be a huge barrier to adherence (much bigger than just plain forgetting). But what is this activista supposed to do about that... bring him some chilli con carne and blondies?
And are most people who miss their appointments doing so because they forgot, or because there’s only one hospital for two districts and they don’t have money for transportation or the ability to be away from home for a day?
These are not easy problems. But would you invest in a program whose primary value-add was reminding people to take their pills and go to the hospital, yet doing almost nothing to help them overcome the very real obstacles to doing those things? Well, in fact, you probably already do: one of my two associations’ HIV/AIDS projects is funded – via the INGO – by PEPFAR (the American government). The other association’s funding is ultimately from the Irish government. (Note: PEPFAR also does some awesome things like making the ARVs available in the first place in countries like Mozambique – a relatively new development.)
But I look at all this money being spent with so little to show for it. And I see the extreme, unmet needs of people in these communities. And I’m left asking: Is this really the best we can do??
I have a Mozambican friend who used to be on the field staff of the INGO that funds one of my associations. One time we were talking about all of this and I’ll never forget what he said: “I know that the majority of the benefit of what (the program he works for) is doing lies at the field staff level: our salaries, offices, cars and computers. I go to the field and I know it’s not doing much. But what can I do? I’m one of them. And I have a family to support. So I say nothing.”
When an organization – or an industry – is getting paid to fight disease and poverty, yet are seemingly more concerned with getting their next government contract than with actually having an impact... aren’t they just profitting off other people’s suffering? Isn’t that... ya know, evil?
In the end, it is a tall order for any one person to change the system. And for those on the inside, there is always the danger of forgetting what you used to know when you spent your days swatting flies. But I personally know at least one person who’s trying: an expat friend in Vilankulo. She consults for one of the big INGOs and is trying to start an organization that would help communities assess their own needs, and help INGOs analyze their impact. And there must be others out there.
Maybe part of the solution is that even more of us – people who know what it’s like on the ground and who want to change things – should go to work for (or alongside) the devil in a white Landcruiser. Because one thing seems clear: he’s not going anywhere.
Okay, I’m going to stop now. My computer is almost dead anyway. And it’s taken all my energy (electronic and otherwise) to talk about this particular topic without it devolving into a tirade. I hope I’ve mostly succeeded... aside from the “devil” moniker. You have to give me that. ;) My apologies if you were expecting something warm and fuzzy like last time. But really, the title should have given fair warning.
There’s a chance you might not hear from me for awhile, since I have, like, 50 business school application essays left to write. That’s how it feels anyway. But I promise to write about something warm and fuzzy next time.
Enjoy your summers!
Julie
P.S. If you’re curious, three excellent books about lessons to be learned from the efforts (failures, mostly) of governments and NGOs to respond to the AIDS epidemic and improve the lives of poor people in developing countries are:
Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty by Abhijit Banerjee and Esther Duflo (so, so good!)
The Invisible Cure: Why we are Losing the Fight Against AIDS in Africa by Helen Epstein
The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS by Elizabeth Pisani
