Archive for November, 2012

"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.


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.


11 2012

Still #1

Pop quiz: what’s the leading killer of children under five?

Before I answer, some background: my impression is that many if not most public health students and professionals don’t really get politics. And specifically, they don’t get how an issue being unsexy or just boring politics can results in lousy public policy. I was discussing this shortcoming recently over dinner in Addis with someone who used to work in public health but wasn’t formally trained in it. I observed, and they concurred, that students who go to public health schools (or at least Hopkins, where this shortcoming may be more pronounced) are mostly there to get technical training so that they can work within the public health industry, and that more politically astute students probably go for some other sort of graduate training, rather than concentrating on epidemiology or the like.

The end result is that you get cadres of folks with lots of knowledge about relative disease burden and how to implement disease control programs, but who don’t really get why that knowledge isn’t acted upon. On the other hand, a lot of the more politically savvy folks who are in a position to, say, set the relative priority of diseases in global health programming — may not know much about the diseases themselves. Or, maybe more likely, they do the best job they can to get the most money possible for programs that are both good for public health and politically popular.  But if not all diseases are equally “popular” this can result in skewed policy priorities.

Now, the answer to that pop quiz: the leading killer of kids under 5 is…. [drumroll]…  pneumonia!

If you already knew the answer to that question, I bet you either a) have public health training, or b) learned it due to recent, concerted efforts to raise pneumonia’s public profile. On this blog the former is probably true (after all I have a post category called “methodological quibbles“), but today I want to highlight the latter efforts.

To date, most of the political class and policymakers get the pop quiz wrong, and badly so. At Hopkins’ school of public health I took and enjoyed Orin Levine‘s vaccine policy class. (Incidentally, Orin just started a new gig with the Gates Foundation — congrats!) In that class and elsewhere I’ve heard Orin tell the story of quizzing folks on Capitol Hill and elsewhere in DC about the top three causes of death for children under five and time and again getting the answer “AIDS, TB and malaria.”

Those three diseases likely pop to mind because of the Global Fund, and because a lot of US funding for global health has been directed at them. And, to be fair, they’re huge public health problems and the metric of under-five mortality isn’t where AIDS hits hardest. But the real answer is pneumonia, diarrhea, and malnutrition. (Or malaria for #3 — it depends in part on whether you count malnutrition as a separate cause  or a contributor to other causes). The end result of this lack of awareness — and the prior lack of a domestic lobby — of pneumonia is that it gets underfunded in US global health efforts.

So, how to improve pneumonia’s profile? Today, November 12th, is the 4th annual World Pneumonia Day, and I think that’s a great start. I’m not normally one to celebrate every national or international “Day” for some causes, but for the aforementioned reasons I think this one is extremely important. You can follow the #WPD2012 hashtag on Twitter, or find other ways to participate on WPD’s act page. While they do encourage donations to the GAVI Alliance, you’ll notice that most of the actions are centered around raising awareness. I think that makes a lot of sense. In fact, just by reading this blog post you’ve already participated — though of course I hope you’ll do more.

I think politically-savvy efforts like World Pneumonia Day are especially important because they bridge a gap between the technical and policy experts. Precisely because so many people on both sides (the somewhat-false-but-still-helpful dichotomy of public health technical experts vs. political operatives) mostly interact with like-minded folks, we badly need campaigns like this to popularize simple facts within policy circles.

If your reaction to this post — and to another day dedicated to a good cause — is to feel a bit jaded, please recognize that you and your friends are exactly the sorts of people the World Pneumonia Day organizers are hoping to reach. At the very least, mention pneumonia today on Twitter or Facebook, or with your policy friends the next time health comes up.

Full disclosure: while at Hopkins I did a (very small) bit of paid work for IVAC, one of the WPD organizers, re: social media strategies for World Pneumonia Day, but I’m no longer formally involved. 


11 2012

Biological warfare: malaria edition

Did you know Germany used malaria as a biological weapon during World War II? I’m a bit of a WWII history buff, but wasn’t aware of this at all until I dove into Richard Evans’ excellent three-part history of Nazi Germany, which concludes with The Third Reich at War. Here’s an excerpt, with paragraph breaks and some explanations and emphasis added:

Meanwhile, Allied troops continued to fight their way slowly up the [Italian] peninsula. In their path lay the Pontine marshes, which Mussolini had drained at huge expense during the 1930s, converting them into farmland, settling them with 100,000 First World War veterans and their families, and building five new towns and eighteen villages on the site. The Germans determined to return them to their earlier state, to slow the Allied advance and at the same time wreak further revenge on the treacherous [for turning against Mussolini and surrendering to the Allies] Italians.

Not long after the Italian surrender, the area was visited by Erich Martini and Ernst Rodenwaldt, two medical specialists in malaria who worked at the Military Medical Academy in Berlin. Both men were backed by Himmler’s Ancestral Heritage research organization in the SS; Martini was on the advisory board of its research institute at Dachau. The two men directed the German army to turn off the pumps that kept the former marshes dry, so that by the end of the winter they were covered in water to a depth of 30 centimetres once more. Then, ignoring the appeals of Italian medical scientists, they put the pumps into reverse, drawing sea-water into the area, and destroyed the tidal gates keeping the sea out at high tide.

On their orders German troops dynamited many of the pumps and carted off the rest to Germany, wrecked the equipment used to keep the drainage channels free of vegetation and mined the area around them, ensuring that the damage they caused would be long-lasting.

The purpose of these measures was above all to reintroduce malaria into the marshes, for Martini himself had discovered in 1931 that only one kind of mosquito could survive and breed equally well in salt, fresh or brackish water, namely anopheles labranchiae, the vector of malaria. As a result of the flooding, the freshwater species of mosquito in the Pontine marshes were destroyed; virtually all of the mosquitoes now breeding furiously in the 98,000 acres of flooded land were carriers of the disease, in contrast to the situation in 1940, when they were on the way to being eradicated.

Just to make sure the disease took hold, Martini and Rodenwaldt’s team had all the available stocks of quinine, the drug used to combat it, confiscated and taken to a secret location in Tuscany, far away from the marshes. In order to minimize the number of eyewitnesses, the Germans had evacuated the entire population of the marshlands, allowing them back only when their work had been completed. With their homes flooded or destroyed, many had to sleep in the open, where they quickly fell victim to the vast swarms of anopheles mosquitoes now breeding in the clogged drainage canals and bomb-craters of the area.

Officially registered cases of malaria spiralled from just over 1,200 in 1943 to nearly 55,000 the following year, and 43,000 in 1945: the true number in the area in 1944 was later reckoned to be nearly double the officially recorded figure. With no quinine available, and medical services in disarray because of the war and the effective collapse of the Italian state, the impoverished inhabitants of the area, now suffering from malnutrition as well because of the destruction of their farmland and food supplies, fell victim to malaria. It had been deliberately reintroduced as an act of biological warfare, directed not only at Allied troops who might pass through the region, but also against the quarter of a million Italians who lived there, people now treated by the Germans no longer as allies but as racial inferiors whose act of treachery in deserting the Axis cause deserved the severest possible punishment.


11 2012

Obesity pessimism

I posted before on the massive increase in obesity in the US over the last couple decades, trying to understand the why of the phenomenal change for the worse. Seriously, take another look at those maps.

A while back Matt Steinglass wrote a depressing piece in The Economist on the likelihood of the US turning this trend around:

I very much doubt America is going to do anything, as a matter of public health policy, that has any appreciable effect on obesity rates in the next couple of decades. It’s not that it’s impossible for governments to hold down obesity; France, which had rapidly rising childhood obesity early this century, instituted an aggressive set of public-health interventions including school-based food and exercise shifts, nurse assessments of overweight kids, visits to families where overweight kids were identified, and so forth. Their childhood obesity rates stabilised at a fraction of America’s. The problem isn’t that it’s not possible; rather, it’s that America is incapable of doing it.

America’s national governing ideology is based almost entirely on the assertion of negative rights, with a few exceptions for positive rights and public goods such as universal elementary education, national defence and highways. But it’s become increasingly clear over the past decade that the country simply doesn’t have the political vocabulary that would allow it to institute effective national programmes to improve eating and exercise habits or culture. A country that can’t think of a vision of public life beyond freedom of individual choice, including the individual choice to watch TV and eat a Big Mac, is not going to be able to craft public policies that encourage people to exercise and eat right. We’re the fattest country on earth because that’s what our political philosophy leads to. We ought to incorporate that into the way we see ourselves; it’s certainly the way other countries see us.

On the other hand, it’s notable that states where the public has a somewhat broader conception of the public interest, as in the north-east and west, tend to have lower obesity rates.

This reminds me that a classmate asked me a while back about my impression of Michelle Obama’s Let’s Move campaign. I responded that my impression is positive, and that every little bit helps… but that the scale of the problem is so vast that I find it hard seeing any real, measurable impact from a program like Let’s Move. To really turn obesity around we’d need a major rethinking of huge swathes of social and political reality: our massive subsidization of unhealthy foods over healthy ones (through a number of indirect mechanisms), our massive subsidization of unhealthy lifestyles by supporting cars and suburbanization rather than walking and urban density, and so on and so forth. And, as Steinglass notes, the places with the greatest obesity rates are the least likely to implement such change.


11 2012

Monday miscellany

  • “Have India’s poor become human guinea pigs?” — a disturbing BBC report by Sue Lloyd-Roberts on lack of informed consent in drug trials in India. Powerful and necessary reporting, especially if the allegations are borne out, but one quibble: reporting on the absolute number of deaths of people in drug trials is not very informative; it’s really more a measure of how many people are enrolled in trials (and what type of trials). Lots of people die during clinical trials — and in fact for trial where mortality is at outcome they must die in the trial if we are ever to measure mortality effects! If you’re enrolling people with heart disease or cancer or other serious diseases in a clinical trial, you might have a lot of deaths in both the treatment and control arms — and the total number would still be large even if the trials are going well and showing huge benefits from new drugs, so just reporting that there were 438 deaths in clinical trials in 2011 is not very informative! The questions are whether a) people are dying at a higher rate than they would have without the trial, and b) regardless of deaths, whether they consented to be in the trial in the first place. The article seems to be mostly (and rightly) questioning the latter, but uses the death counts in an potentially alarmist way.
  • “The sea has neither sense nor pity: the earliest known cases of AIDS in the pre-AIDS era.” This is a fascinating read from the blog Body Horrors, recounting the story of a Norwegian sailor who acquired HIV in the 1960s, and subsequently died from AIDS (along with his wife and daughter) before knew what AIDS was. One thing the piece doesn’t point out is that while this is the earliest known case of AIDS, the earliest known case of HIV is from an (anonymous) blood sample from the Congo in 1959 — background on that case in Nature here.
  • The British Medical Journal will require all clinical trials to share their data, starting in January. Hopefully other journals will follow their lead. This is big — more soon.


11 2012

Friday photos: Somaliland

I have lots of thoughts on my trip about one month ago to Somaliland, as it’s a fascinating place — highly recommended in particular for students of public policy or development. But those will have to wait for future posts as I’m swamped for now with work, my Masters thesis, and some other projects. In the meantime, this is Hargeisa:

Above, a major mosque. Below, the street scene downtown:

The animal market:

And here’s me with a moneychanger and stacks of Somaliland shillings:


11 2012