"The many faces of Martine Ojuka" and Other Stories

Subtitle: A Children's Treasury of Tales of an ADD Field Officer

Prologue: Martine Ojuka is a member of the WASH Benefits field team. In a small number of ways, he is just a normal team member, completing his surveys and leading community meetings. In a not-so-small number of ways, he is a total goofball. If WASH had a yearbook, Martine would be voted "Most Likely to Be Prescribed Massive Doses of Ritalin". These are some of his stories.

Chapter 1: The many faces of Martine Ojuka

It was an exciting day in the WASH office: some high-tech, motion-sensitive video cameras had just arrived from the University of Buffalo in the US, fancy new tools to help us monitor people's handwashing behavior and encourage them to wash more often. And when it came time to pick someone to be in charge of giving our babies a little test drive, I had only one name in mind.

Half an hour later, Martine shuffled back into my office, clutching the camera and grinning in the kind of way someone who is bad at keeping secrets grins when they are trying not to tell you about the surprise party  My eager queries about how it went, whether they had figured out how to use the motion sensor, and how easy the device was to assemble and disassemble were met with stifled giggles. I suspect this may be why:

I still have no idea whether the motion sensors work or not. They never quite managed to achieve that fifteen seconds of motionlessness required to turn the camera off. Actually they never really came close.

Chapter 2: Martine, Lord of the Flies

Here on the WASH team, it's our job to leave no stone unturned when it comes to figuring out how little kids could possibly be getting all that diarrhea. One possible route we are currently exploring is the large number of flies you'll find upon entering any Kenyan compound: could they really be more than cute, innocent little house guests?


First, I set Martine to work on a literature search to come up with any existing research on fly species in East Africa, their prevalence and seasonality, and any evidence about their role as disease vectors. What follows is a partial list of the titles his efforts uncovered:


"A sample survey of selected areas in and near Little Rock, Arkansas, to assess the prevalence of Entamoeba histolytica."


"Studies on diarrheal diseases in Central America: Preliminary findings on cultural surveys of normal population groups in Guatemala."


"Selective primary health care: is efficient sufficient?"


"Environmental factors in the relationship between breastfeeding and infant mortality: the role of
sanitation and water in Malaysia."


You may have noticed a common thread to these articles. I, on the other hand, did not, unless that theme was "ARTICLES THAT ARE NOT ABOUT FLIES IN AFRICA". The one article that had anything to do with Africa at all was a study from Zambia talking about piped water. I decided that perhaps there were more productive uses of Martine's time and declared the literature sufficiently exhausted.


Over the next few days, I put Martine to work constructing cheap fly traps from leftover plastic bottles, going around to local butchers for rotten meat scraps to use as bait, monitoring fly activity around the traps at various times throughout the day, and finally speciating the flies he caught using rubber gloves and google images. I was amazed at how thoroughly and quickly he took to each task. I think he felt a certain bond of brotherhood with the chaotic little creatures.


A few days after the completion of the fly trap trial, I ran into Martine and Fredrick (another field officer) walking down the hall in a heated argument. Thinking this was probably something to do with Martine stealing the "e" that properly belonged in Fredrick's name and sticking it rather unnecessarily on the end of his own, I didn't think much of it until they stopped me, with very serious expressions, and said they wanted to ask me a question: "Andrew, these fly traps. Are they part of sanitation? Or hygiene?"


Of course, this made me feel like a proud parent with a teachable moment, and I launched into a lecture about how we could really see elements of both, blah blah blah, something ridiculous, something boring, and finally, if I had to choose I would probably say sanitation.


At this point Fredrick turns to Martine, slaps him on the shoulder, and shouts the Swahili equivalent of "I told you so!", and Martine, looking thoroughly chagrined, took fifty shillings out of his pocket, slapped it into Fredrick's hand, and slouched off grumpily. Fredrick, looking elated, rolled his eyes and asked me incredulously "Can you BELIEVE he really thought it was hygiene?!"


For those who are wondering, I do in fact have a gambling-based community educational curriculum in the works. Possible titles include "How to gamble with your health--and win!" or "WASH: you can bet on it." I also choose to view the fact that my field team is now confident enough in its WASH knowledge to start putting money on it as a sign that I am doing something right, and not as a sign that they are also secretly betting on how many times I will have to ask Roselyn to repeat herself as she greets me in Swahili.

Chapter 3: Martine Discovers the True Meaning of Asthma

Once upon a fine sunny day, the WASH team was happily sitting around discussing potential sources of contamination that young children may come into contact with in their daily activities around rural households. All was well with the world, until Carson and Andrew decided to take a perfectly good discussion and wring the last drop of fun out of it by turning it into an actual, standardized survey.

Amid the general boredom that ensued, the field officers entered into a grave debate over whether it was important to distinguish between times a child comes into contact with pets (e.g. dogs, cats, rocks) and those times when he or she comes across other domestic creatures (e.g. cows, chickens, goats, sheep, donkeys). Martine distinguished himself for being adamantly against the idea that pets posed any threat to a child, advocating that they should be left out of the equation altogether. Most of the others had a more suspicious view of pets and their germy-ness, so Martine called a recess in order to research the matter further.

About an hour after our discussion had concluded, I received an e-mail from Martine with the following tantalizing subject line:

It's long but read through to the end. We continue tomorrow

All right Martine. I'm curious. I'll bite. And the first lines did not disappoint: "Remember that idea (Question by Duncan) that we do away with either code 9 or 10 in the list of things that children come into contact with at home? PETS ARE EQUALLY DANGEROUS."

Wondering what research could have prompted such an abrupt change of heart, I scrolled down a little further. Ah. Yes. The Dog and Cat Management Board of South Australia. How could I have forgotten their earnest warnings about the potential for allergies and asthma attacks in children who come into contact with household pets? Or that cleaning out a litter box can put pregnant women at risk for toxoplasmosis? Or--seriously, where was my head?--the threat of psittacosis posed by the presence of a budgerigar in the home??

The full manifesto included stern warnings to "Make sure children do not try to go near dogs that are eating or

sleeping because dogs can become angry if disturbed" and "Young children should never be left unsupervised with a dog, even the family pet!"

In all honesty, I was really proud that he was so willing to do the research and not to switch his opinion when confronted with contrary evidence. Changing that "contrary" to "convincing" is a bit of a work in progress.

***

Signing off from Nairobi. St. Louis, I know I asked (begged) for snow. Now I just want you to let my plane in. Please.

Uh, no, America. You can stop patting yourself on the back now.

I hope to have one more post coming before I fly out this weekend, but in the meantime here are some fun and not-at-all-concerning numbers about American perceptions of the US aid budget:

From the American Public Opinion on Foreign Aid Questionnaire: November 30, 2010 (Source: worldpublicopinion.org)

Percentage of federal budget Americans think goes to foreign aid: 27%

Percentage of federal budget Americans think SHOULD go to foreign aid: 13%

Percentage of federal budget that ACTUALLY GOES TO FOREIGN AID: 0.6%

Allow me to submit my own mini-questionnaire: If you are a foreign aid policy analyst looking at these numbers and trying to construct your financial projections in half for next year based solely on the knee-jerk opinions of 848 random Americans, do you:

a) Slash your budget in half ("But America, you said we were giving twice as much as we should be!")
b) Increase your budget by a factor of 20 ("But America, you said we should be giving 13%!")
c) Hide under your desk and cry.

In theory, I guess, this could be seen as good news: way back in 1995, Americans weren't nearly as optimistic about their country's imagined generosity, and perceptions of how much we "should" be giving are certainly higher...

This isn't to say that our aid budget is too small or that America should be giving anything close to 13%. It's mostly just to make fun of how clueless we all are about the amount of good our country actually does in the world, and we should be wary of overestimating it. But if you're looking for some redemption, America, there's always reality TV. (Yeah, you can file that one under "sentences I never thought I'd write with a straight face".)

Some aesthetic therapy, courtesy of Lake Victoria

Anything I say will just make it less beautiful:

"It's like there's a chapati in your mouth and everyone's invited"

I hope you all had a very happy normal Thursday this week! I know I did. For no particular reason, I have decided that today is a good day to write about Kenyan food and how much Kenyans love to feed visitors. I also have this weird urge to say that I am very thankful for my field team, the end of the rainy season, the fact that I am coming home in two weeks, and pineapple.

Without further ado, dear readers, I present to you the menu of literally every single home and hotel in Western Kenya. Whoever said variety was the spice of life forgot that Kenyans don't like spicy stuff very much. (Sorry, I lied. Brief further ado: eating establishments in Kenya are called "hotels" as a holdover from the days of British colonialism, when really the only restaurants in the country were those at the hotels catering to Europeans--the word association apparently stuck with the food rather than the lodging, so now if you walk into an establishment in western Kenya that has "hotel" on its sign and ask for a room, they will probably smile and offer you their own bed as they are secretly confused by this unusually demanding customer and wonder how you can eat ugali in bed.)

And now, your specials for this evening:

Ugali - A pale, pasty, lumpy, Play-doh-textured concoction made from maize, served at temperatures usually reserved for melting precious metals. That way, when you follow the local custom of picking it up with your hands and molding it into a kind of edible spoon, the third-degree burns on your fingers conveniently distract you from its complete and total lack of taste. You can ask any Kenyan and they will tell you that a meal without ugali does not count as a real meal, because you cannot possibly feel full unless you've had it. Translation: ugali is a dense delivery vehicle for empty calories to help people feel like their stomachs are full, as they're not likely to have an abundance of other food most days. Tastes like: Nothing. Not as in "like nothing you've ever tasted." As in "nothing." Utterly flavorless. Alternatively, if I could remember what Play-doh tastes like, I suspect ugali would only be slightly worse than that.

Maharagwe - A kind of bean stew. Tastes like: Imagine you are a Mexican cowboy dreaming of some refried beans. But then you forget to refry them and they just turn out kind of liquid-y. You would be an unhappy cowboy, but you would probably still eat them. And they would be okay, but in your mind you would be like, "Ay caramba! These beans could be so much better."

Sukuma - The cheapest locally available vegetable, it kind of looks like green confetti when it's shaved from the larger head. It's also known as "sukuma wiki" (wiki being Swahili for "week") because poor Kenyans will often eat only ugali and sukuma for the last week of the month before they get their paychecks. Tastes like: Spinach. Mixed with grass.

Ndengu - Stewed green lentils. Tastes like: Has kind of a dry, dirt-ish texture, and a savory, dirt-ish flavor.

Kechambari - Sliced tomatoes with onions. Tastes like: Depends where you get it. When properly mixed with dhania (cilantro), it's got a nice pico de gallo flair to it. Otherwise it mostly tastes like tomatoes.

Samaki - Tilapia from Lake Victoria, usually served whole roasted, so that you get to really dig in there with your fingers behind the eyeballs to politely get those last bits of meat out. Of course, if you're really polite, you'll just eat the whole head and not bother with the whole business of distinguishing between meat and organs. Tastes like: Uh, fish.

Kuku/nyama/mbuzi - Kuku = scrawny chicken. Nyama = scrawny beef. Mbuzi = Really scrawny, greasy goat. Tastes like: Hard to say, I'll let you know when I've finally finished chewing.

Wali - Rice. Tastes like: Rice.

Chapati - An oily flatbread, similar to naan but thinner and with less flavor. Tastes like: Freedom.

Matumbo - To understand the story behind matumbo, I need to tell you about my field officer David. David comes from Luo-land, the area where my project does most of its work, so when we're eating lunch out in the field he always takes it upon himself to order something new for me. The first time we tried this system, I ended up with matumbo, which appeared to be some kind of stew with splotchy tubes floating around in it. When I asked David what it was, he would only say, "Just try!" I tried it, thought the rubbery texture was a little weird, but decided it wasn't terrible and gave David a thumbs up. He smiled at me. "It's cow intestine!" Tastes like: Honestly, it tastes like beef. And feels like octopus.

Omena - Another David order, this one was a little easier to visually identify. Omena are tiny fish, cooked until they are dry, crispy, and salted. And actually, they're pretty darn good. Tastes like: What you get if you put anchovies and potato chips in your combination fuse-o-matic shrink machine.

Maziwa chungu - This one was introduced to me by Nellie, another of my field officers. The name in Swahili literally means "sour milk," which has my vote for "Swahili understatement of the decade." This is whole milk that has been allowed to curdle until it gets chunky, and unlike omena, it is not good. Nellie made a deal with me when she served me a glass that if I could make it halfway through within ten minutes, she would drink the rest. I dumped three large spoonfuls of sugar in and gagged my way through for about half an hour before she got impatient, snatched it away from me, and drank the whole thing in two gulps. Apparently this is quite the delicacy in Kenya, because just then Duncan, yet another field officer, walks in and exclaims "Ay, chungu! Why did you not serve me as well?", prompting Nellie to scold me for being too slow, because "now everyone will want some!" Tastes like: Don't ask, don't tell.

By this point, you may have picked up on a general distaste for Kenyan food coming from my direction. I just want to say...yeah, that's basically true. But it does grow on you: there's not a day that goes by when I don't have ugali, sukuma, maharagwe, ndengu, or chapati at some point, and it's not bad at all (the fact that we flavor everything with tabasco sauce and chutney smuggled in from the states doesn't hurt either). I don't even miss stuff like cheeseburgers or apple pie or genetically-enhanced chicken anymore.

Haha, yeah right. First thing I'm eating when I get off that plane.

A Not-Quite-Yet-Insider's Guide to Surviving Field Work in Africa, Part II

Well, I would say it’s been one of those weeks, but by this point it’s been far more than seven straight days of insanity here. Let’s call it one of those months. The kind that reminds you irresistibly, relentlessly every moment of exactly what kind of place you live in now, that forces the question “why am I in Africa?” into your mouth, then answers it magnificently before you have the chance to gulp. I’ve had some of the most frightening experiences of my life over these past few weeks, but I’ve also got nothing but optimism for the way things are heading here, which is an interesting tension to live in. The fact that I have so many stories and no time to tell them has been steadily eating away at me these recent weeks. It’s good to be writing again.

As a gift to my mother, who will undoubtedly be even more desperate to see me firmly planted back on North American soil after reading this, I have now included a helpful countdown to the exact moment my plane is scheduled to touch down in St. Louis. Not that it’s really possible to improve on your current rate of visits per day, Mom, but at least now you have a slightly better excuse for refreshing the page than “Hmm…I know it’s technically 4 AM Kenyan time and I just checked ten minutes ago, buuuuut …maybe he stayed up really late just to put up a new blog post!” (Just kidding, love you Mom!)

Now where were we?

***

Scenario A:  The Abducted Automobiles

Andrew’s Solution: Well, first of all, let’s get one thing out of the way: don’t bribe. Ever. It’s expensive, it sets a very bad precedent, it lowers the status of your organization within the community, it creates an incentive for further police shenanigans, and it’s utterly repulsive from a moral standpoint. Bribes are kind of like the hard drugs of development work: they may seem like a quick and easy escape from your problems, but once you start down that road it’s nearly impossible to get off. Also they’re both illegal. Just say no. Try something like this instead:

                Step 1: Try to reason with the police.

                Step 2: Pretend to shoot yourself in the face.

                Step 3: Wait ten minutes, then go back to step 1.

This will only be fun for about three hours, at which point I would suggest polling your field team to see if any of them have a relative on the police force (don’t be picky here—any old cousin, brother’s wife’s uncle, or crazy grandma’s neighbor’s son will do). Have them call and spend some time catching up, reminiscing, “how’s your mother”-ing, cajoling, threatening to tell mom or skip the next family reunion—whatever it is Kenyans do when they want a favor from someone. Then try to act gracious and nonchalant when the police mysteriously show back up at your gate a few hours later. “Sorry, you want to return what now? Oh, you mean THOSE field vehicles. I completely forgot they were gone…you can just put them anywhere. Asante sana, see you at the next roadblock!”

Scenario B:  The Bogus Blood Burglary

Andrew’s Solution: After wiping that incredulous smirk off your face and coming to terms with the fact that this is actually happening, you need to act fast. This is the kind of thing that can permanently prevent you from working in a certain area, and it can harm the work of other aid agencies too when they arrive. Send your best communicators (both Swahili and the local dialect) and friendliest government contacts to the village as soon as possible to hold a community meeting and clear up the misconception.

Then never send your team to the field in a red car ever again. Ever.  I am entirely serious. IPA no longer employs any red cars in its vehicle pool for this very reason.

Scenario C: The Guilty Guide

Andrew’s Solution: You actually might not end up having a whole lot of say in this one, so try to trust that your field officers have received excellent training and possess something resembling common sense. Your field officer may decide to take this one solo, as mine did, opting for the rather cheeky move of calling the arrested man’s wife and asking her to take over his guide duties. I would have taken a slightly different approach, something like “Stay there, wait for us to find another guide and come get you, and by all means don’t go increasing your association with the accused by calling his wife, who is probably not the cheeriest woman in Kenya at this moment.” Shows how much I know.

Scenario D: The 4-by-4 Fake-out

Andrew’s Solution: Huh. You are stuck on a muddy hill with an uninsured, unsafe vehicle in the middle of nowhere. The obvious first step I know you’re all thinking of is to spend an hour on the phone ordering a new insurance policy for the vehicle and making sure it can be available the following morning. This will leave you stuck on a muddy hill with an uninsured, unsafe vehicle in the middle of nowhere, an hour closer to dark than when you started. The police may or may not be friendlier by this point. If you have been really laying the charm on (if anyone asks: why yes, Kenyan police officers are in fact much tougher than all those American police officers you know), they might even offer your team a ride back to town.

Scenario E: The Suspicious (and Not-so-Sober) Spouse

Andrew’s Solution: Despite the unfortunate situation it put your team member in, this one’s easy. Make sure it’s always a female field officer that visits this household in the future. Tell your male field officers they are not allowed to conduct interviews inside the house, but must sit outside when administering the survey. If you want, you can advise them to ask each respondent for a small bucket of water upon entering the compound, to be thrown upon any intoxicated intruders.

Scenario F: The Awful, Awful Arrests

Andrew’s Solution: There are no jokes to make about this one. We were told in no uncertain terms that the absolute worst thing we could do would be to show up and demand their immediate release. Aside from the very real risk that we ourselves would be put under arrest as collaborators, our presence would only signal the presence of potential bribe money, turning an obstinate process into an impossible one. It’s an incredibly helpless feeling to be told you can’t even go see your team in jail, bring them food, tell them it’s going to be all right…nothing good happens in Kenyan prisons: diseases and beatings are as numerous as the inmates themselves, and our team found themselves on the receiving end of both. With the help of a diligent Kenyan lawyer, we were able to secure their release two days later, at which point several of them were admitted to a local hospital. Although legal action could have been taken against the police (and against the local radio station which reported that we were organizing a thievery ring in the area), our interest in continuing to work in this district dictated otherwise. Asking your field officers to go back to an area where they’ve been arrested, abused, and labeled community menaces is nobody’s idea of an ideal situation, especially not the moment you’ve finished telling them how thankful you are for their safety and the perseverance they’ve shown. I can’t say enough about how unbelievably dedicated and passionate they are.

***

To be fair, these are among the more dramatic situations that I’ve faced, and I have a great support staff to help me handle them. A description of the elusive (read: imaginary) animal known as a “typical day in Kenya” would include much more mundane fare: village elders forgetting to notify their communities that your team is coming, leaving you with a few hours worth of thumb-twiddling while guides and respondents are assembled; vehicles getting stuck in the mud; respondents going on safari, going missing, or falling ill; field officers getting scared off by snakes while doing observations or community meetings…nothing special.  Here are some more general tips I’ve found useful in dealing with such things:

1.       Laugh. A lot. Let’s face it, this stuff is RIDICULOUS. I don’t want to make light of any of the serious, dangerous situations my field officers and I have found ourselves in, and I especially don’t want to make sport of ignorance. I do want to recognize that there’s a lot of humor to be found in the unexpected, the bizarre, and the completely irrational—if I couldn’t smile at it when some policeman gives me the most transparently bogus reason for asking my team for money…there would probably be fewer confused policemen wondering why the weird white guy is laughing at their very serious requests. And I would have less fun.

2.       Adjust your expectations for plans and circumstances; keep them high for people. Corruption, drunkenness, violence, dishonesty—these things aren’t African, they’re human. It’s one thing to be wary of situations that could fall apart or put your team in uncomfortable places; it’s another entirely to be wary of people and assume the worst of them. I believe in Kenyans, even if their country hasn’t yet given them the institutions to put them in a position to succeed honestly.

3.       Invest some quality time in building the perfect “time to be patient” playlist in your iTunes. Mine is usually headlined by Arcade Fire’s “We Used to Wait” followed by healthy doses of K’Naan and The Beatles.

4.       Never pass up a chance to introduce yourself—Kenyans are crazy connected, which kinda just happens when you have a couple hundred people in your extended family. This means that anyone you meet could have a cousin on the police force, or in the government, or that works as an auto mechanic, or that cooks really good chicken gizzards and sells used batteries on the side. Investing in a relationship with one Kenyan, worthwhile in its own right because they are all fascinating people with compelling stories, could connect you to half the town.

5.   Have faith. I am absolutely and irrevocably against hackneyed, feel-good platitudes that get whipped out in situations like this with the implication that the worries of life flee in panic at their very utterance. I’m doing it anyway. Sometimes that’s all there is.

***

Life outside of work is rarely easier to make sense of. Things get stolen, transformers blow up, people demand bribes, friends lose children and relatives to disease or accident, the local market doesn’t have any decent peanut butter…and Saturday, not 40 yards in front of me, I watched a speeding, fully loaded oil tanker veer off the terrible, dangerous, potholed road from Kisumu to Busia. It looked for a moment like the driver would find a way to stay upright, but the next instant it swung past the point of no return, flipping completely over at full speed, finally coming to rest with the driver’s side smashed against the road and the tank leaking its volatile contents onto the dirt shoulder. While a small crowd chattered around the cab, obscuring my view of whatever may have happened to the driver, most of the nearby villagers, as though some happy trick of memory allowed them to ignore the fact that ten seconds earlier they were meters away from being crushed, were hurriedly hunting for jerry cans, buckets, anything they could find to collect the precious leaking fuel. Praying that no one decides to light up a cigarette, sending this action movie disaster scene to a tragic special effects finish, I hurried reluctantly away from the crash site. There would be no police investigators there to take my witness statement, no ambulances rushing to the scene from a nearby health center—it feels wrong to leave such scenes.

Sorry for freaking you out, Mom. 20 days to go.

A Not-Quite-Yet-Insider's Guide to Surviving Field Work in Africa, Part I

A huge part of my job here in Kenya is overseeing field work for my team. When everything goes according to plan, this involves coordinating the delivery of various interventions, administering surveys, conducting focus groups, and leading community meetings in the villages where we work. The percentage of time that everything goes according to plan is probably something like negative 83% (the negative is for all those times when the plan finds an astonishingly high number of ways to go wrong, or when the back-up plan and damage control plans also crash and burn). The end result is that very often I am really just a glorified fire extinguisher.

So to help you get a bit of a feel for my job, I present to you six of the most entertaining, head-scratching, face-palming, and occasionally frightening fiascoes that have beset my team these past few months. As a fun little exercise, I have also left them without resolution, so you can play along at home and come up with your own responses.

Three of these stories have happened within the past week. All of them are 100% true. They are also 26% frustrating, 74% silly, and 1,000,000% ridiculous:

Scenario A: One morning, just after shooing your team out the door like a hen-pecked parent, you return to your office to enjoy a nice cup of tea and set about some other business, only to find your team traipsing back in through the door five minutes later, a chorus of car horns ringing from the yard behind them. The Busia Police, it appears, having not yet received their pay for the previous month, have decided to recoup their losses by declaring today "Vehicle Inspection Day!" and charging fees for towing and processing the impounded vehicles. The rules are pretty simple: Vehicle doesn't have a valid insurance sticker? Impound! Vehicle does have a valid insurance sticker but it looks slightly sun-bleached? Impound! One of the rear seatbelts doesn't buckle? Impound! Vehicle has absolutely nothing wrong with it but "looks like it might be stolen"? Impound! You now have no field vehicles, an entire field team with no activities for the day, and a very stubborn police force on your hands. Go.

Scenario B: You are starting a new child health pilot in a village to look at how you can help mamas keep their compounds more sanitary. You begin by holding a community meeting and focus group, followed by a baseline survey among a few selected respondents. Everything goes spectacularly well on the first visit: people are warm, receptive, and thankful for the fact that you are working in their community. When your team returns, however, they are met with a very different response: the villagers are cold, hostile, and suspicious. They drive your team members away, accusing them of (what else?) wanting to steal the blood of the village's children. As it turns out, another NGO had also been doing some child health work in the area, in a neighboring village. As part of their project, they had taken some blood samples--maybe to test for malaria, HIV, other diseases, who knows--but hadn't yet returned to follow up or announce the results. Naturally, the neighboring village assumed that the NGO had really only been after the blood all along and that the whole "child health" story was just a front, and they quickly begin to spread the word to their neighbors to be suspicious of any outside group that comes in asking about the health of their children. The fact that your team arrived on its first visit in a red car obviously doesn't help anything (red, I don't think I need to remind you, is the color of cherries. Also blood, which may be more relevant here). You now have a whole village that thinks IPA is a blood-sucking agency of the devil. Go.

Scenario C: While in the field, team members often recruit a community member to guide them around to the various compounds they need to visit. In most cases, the village elder selects upstanding residents of the village to carry out this task. In others, the guides are of a less reputable constitution. One day, you receive a call from one of your field officers informing you that her guide, a rather suspicious-smelling individual, has been arrested on charges of assault, and that, in the long-standing Kenyan tradition of "guilty by association until proven innocent (or until exonerated by that crisp new 200 shilling note that somehow found its way into the policeman's pocket)", the police have also levied accusations against her and demanded to search her things. She now has no guide to get her back to the rest of the team and a very suspicious policeman on her back. Go.

Scenario D: You are traveling with your team to an area known for its steep terrain, poor roads, and constant rain, the kind of place that eats your normal field vehicles as a pre-breakfast snack. To keep your team safe and on track, you enlist the services of a driver who claims to have a 4x4 vehicle that can accommodate all your needs. Once you arrive at your destination, it quickly becomes apparent that your driver has a bit of an honesty problem when, after fishtailing your way up a muddy slope, you abruptly find your vehicle facing the opposite direction of the one you are trying to travel. When some friendly police officers stop by to help push you out of the mud, you discover that your driver's claims about having proper insurance for his vehicle were also somewhat exaggerated. You are now on a muddy hill in the middle of nowhere with no proper mode of transportation back to town and your only ride about to be impounded by the police. Go.

Scenario E: While conducting a survey with a mama in a rural village somewhere, one of your field officers is suddenly confronted by the woman's husband, who has returned home in the middle of the day, completely drunk, and has decided that your field officer's whole "Can I ask you a few questions about hygiene in your compound and community?" routine, with its fancy "clipboards" and "surveys", is really just an elaborate strategy to seduce his wife. His reaction is less than peaceful. Your field officer manages to get away, but the team is wary of returning to this particular compound or even village again. Go.

Scenario F: While on a survey trip that requires your team to camp for a week in a town a few hours from Busia, your field officers return to their guest house from the day's work to the sound of gunshots in a back alley (which is a very rare occurrence in Western Kenya--gun violence is virtually non-existent here). When the boys in blue come to investigate, the locals helpfully volunteer the information that your team has been out scouting homes in the community all day, clearly indicating that they are a crack team of violent home robbers casing out their next victims and happened to carelessly give themselves away with some casual gun-play. Your entire team is immediately arrested and held overnight in the local prison. The next day, the local prosecutor insists on questioning each team member individually for several hours, making it impossible for you to bail them out. Go.

My bosses are coming to Kenya next week and I have a lot to do to prepare for their arrival, so you'll have plenty of time to come up with and submit your own creative strategies for restoring sanity in each of these situations. Except Scenario F. If you have a potential solution to Scenario F, you should forward it immediately to ahoekzema@poverty-action.org. Like, now. Please.

My own responses (not to be confused with "correct responses") will be coming soon.

IPA and the cult of randomization

First of all, thank you so much to everyone for all the birthday wishes and phone calls on Sunday! I know I’m way behind on my thank-yous, but you guys mean the world to me and it was more than a little wonderful to hear from everyone. In fact, I’m more than a little intimidated by the sheer number of you that got in touch with me, because as frighteningly long as my list of people to write to was before, it’s now reaching dangerously unattainable levels.

For those wondering what a Kenyan birthday celebration looks like, I have just three words for you: I don’t know. According to my housekeeper Millicent (whose birthday, ironically, happens to be today), most Kenyans in this region don’t have money for parties or gifts, so birthdays just aren’t a big deal. For my part, the two best things about my birthday were (1) treating myself to a large bowl of Frosted Flakes, which I had managed to find in Nairobi the weekend before, and (2) my friends here surprising me with 5000 Kenyan shillings worth of cell phone airtime to call home, which at my current rate is equivalent to nearly 30 hours of international calling time (or 2500 international texts, take your pick). If you want to get really sick of hearing from me, give me your number.

Today, as a preface to the ever-delayed and long-overdue post on what I actually do every day here, I’d like to give a bit of an introduction to Innovations for Poverty Action as an organization and how it fits into the current trends of international development work. If you haven’t gotten around to reading the previous two posts yet, now would be a good time to quit this one and go read those first. Not because they’re necessary or good or any nonsense like that, it’s just that this one is really long and kind of nerdy and you might want to warm up a bit.

Innovations for Poverty Action is first and foremost a research organization (we have to be specific about that “research” part here in Kenya, because if we bill ourselves as a “development” organization, everyone will expect that we are just here to hand out money and medicine and things like that), and it subscribes to a very particular research methodology. When evaluating development programs of all stripes (microfinance, HIV education, community funding of public health interventions, controlling political corruption, getting farmers to invest in fertilizer and other forms of agricultural technology, helping rural families start savings accounts, vocational education vouchers, and community chlorine dispensers are just a few of our projects going on here in Kenya—check out IPA’s website for the full list of programs we’re evaluating around the world), the IPA model is to borrow a research method most often used in medicine and public health called a randomized controlled trial, RCT for short.

Those of you who are fellow RCT aficionados, indulge me a few minutes of explanation. The rest of you might be most familiar with this method for its use in evaluating pharmaceuticals or novel medical therapies: in clinical trials, patients are randomly assigned to a “treatment” or “control” group, and the effect of the new drug or therapy is measured by comparing the outcomes of the treatment group to those of the control group. It’s the scientific “gold standard” for evaluating the impact of a treatment in situations where we can’t know exactly what would have happened in the absence of that treatment.

IPA, however, is unique in the way that it takes this methodology and applies it to problems of economics, development, and foreign aid. One of the trickiest parts of evaluating development schemes is that you can never really know the counterfactual—that is, you can never know what the outcome would have been if your scheme had never been implemented. Maybe your elementary reading program showed that kids are doing 20% better on reading tests now than they were previously—but is that actually because of your program? Maybe a good harvest that year meant the kids in your program were getting better nutrition and their parents could afford to send them to school more often. Maybe new trade or pricing policies changed the average income in the area where you were working. Maybe the year the kids in your cohort were born, there was an especially good crop of green plants so their mothers ate more folic acid while pregnant, or maybe there was an iodine supplementation program going on then which resulted in improved cognitive development. It gets really messy trying to sort out all the possible variables that could have contributed to the gains you saw. RCTs offer us the best way of equalizing those variables across our experimental groups and isolating the true impact of a program. And right now in the world of economists (as opposed to the real world), randomized trials are like the shiny new toy that everyone wants to play with, despite the fact that it’s been sitting in their mixed-metaphorical toolbox of research instruments for years.

Consider that The Economist magazine, in its 2010 Innovation Awards, named "Randomized trials of aid and development schemes" as one of only seven nominees for the idea that will have the biggest impact on society in the next decade (the other nominees? 4G Networks, Geoengineering, Private space-launch services, Graphene electronics, Personal genomics, and Electric cars. Weird, right? Yeah, I don't know how "Jersey Shore" didn't make the cut either.) Esther Duflo, an MIT economist who helped found both IPA and its sister organization J-PAL (Jameel Poverty Action Lab), along with being one of the youngest tenured professors in MIT's history, was recently awarded the Clark Medal (second only to the Nobel in terms of prestigious economics prizes--former winners include Milton Friedman and Freakonomics co-author Steven Levitt) as the most accomplished economist under the age of 40. She has a Macarthur Genius Grant. She was invited to give one of the keynote addresses at this year's TED Conference. When the New York Times wants a quote on poverty and the Millennium Development Goals from someone that's not a one-named U2 singer, they call her. If all of that is too nerdy for you, fine, let's whip out the big guns: Oprah just named her one of the most powerful women in the world. Chew on that.

(Incidentally, she is also a charming if somewhat impatient woman with a low tolerance for poor French pronunciation. Her introduction to my colleague Thomas and me went something like this: "'Ello, I am Esther. You will find I am short, slightly left of center, and very French." We did, in fact, find that. Especially the French part.)

My own boss, Harvard's Michael Kremer, is practically pedestrian by comparison despite a Macarthur grant of his own, having managed to completely evade the Oprah radar with his paltry offers from USAID, his 2004 Arrow Award for the most influential economics paper of the year (based on de-worming research done right here in Busia), and the fact that he has essentially written the book on funding vaccine research for tropical diseases, finding markets to deliver needed immunizations to the world’s poorest consumers.

The point of all this isn't to impress you. You already know I’m a nerd, and honestly, I would feel weird if all of you--scratch that, if any of you—actually got excited at the mention of the Clark Medal or Arrow Award. The point is that after years and years of unaccountability and foreign aid based on ideology, politics, and Western perceptions of what developing countries “really need”, we feel like we’ve finally come up with some reliable tools to tell us what types of aid are most cost-effective and having the biggest impact, and the people developing those tools are getting a lot of attention. IPA is now routinely approached by governments and NGOs hoping to get their new programs evaluated, and designing many of these trials is a uniquely challenging process. Randomization in development trials isn’t as easy as it is in clinical trials of new prescription drugs, and Michael, Esther, and others have done a fabulous job of coming up with creative ways of measuring impacts, whether it’s randomly phasing in programs over several years, or randomizing at multiple levels, or rotating a program randomly between certain districts over time.

Once our research shows that something really does work, that a program is cost-effective, that a novel idea has a much bigger impact than anyone was expecting, IPA also has teams in place to help take these successful solutions to scale. We disseminate results to policymakers and officials, and we also push forward on our own partnerships to help fund and expand good programs. Perhaps the greatest success story so far has been IPA’s work with de-worming: research in primary schools in and around Busia about a decade ago was able to show that providing students with a single dose of de-worming medicine (an extremely cheap and easily administered intervention) had a huge impact on school attendance, as kids spent fewer days sick at home. That seems obvious. What wasn’t obvious was that this effect actually extends not just to the schools receiving the treatment, but to all the neighboring schools as well—de-worming at one school made it harder for worms to be transmitted from child to child and protected children in surrounding villages to a significant extent. IPA’s calculations found that the total benefit from these de-worming interventions, based on the total increased school attendance and improved health of all children involved, made it one of the single most cost-effective public health interventions in the world. The program is now being implemented in all high-risk primary schools in Kenya and it will continue to expand on a global scale. More info is available at Deworm the World. (If you want to read the award-winning paper on this research, you can wade through Michael's ridiculous publication list to find it here).

Although RCTs have done a lot of good for the world of development economics, reducing bias, isolating impacts, and saving money in the long run by isolating the most effective programs, there are a number of significant ethical and cultural concerns that come into play when implementing such trials in a developing context. They’re expensive and tough to carry out. It’s difficult to study rare or distant outcomes. They might not be easily generalized to outside contexts. And like all trials, they are subject to certain statistical limitations. The most important considerations, though, when implementing an RCT in a developing country, are those surrounding the consent and perceptions of the people who are actually enrolled in the trial. The subjects of our research are real people with real lives, people who often aren’t empowered economically or politically. Getting informed consent from these populations requires being really sensitive to what “consent” means in this context, and how people are going to perceive something like a randomized trial. A program which specifically enrolls some people who are not going to receive aid can be seen as incredibly unfair (even though we allocate as much of our budget as possible towards our actual interventions, and only enroll enough controls to ensure that we can make definitive statistical statements at the end of our study), and we need to be sensitive to that as well. It’s a fine line to walk sometimes, but in general my personal experience has been that people are grateful for our presence, regardless of how much aid we give their household individually.

We know aid isn't the be-all and end-all of development. In the long run, aid isn’t the sustainable or most successful means of improving people’s lives. We also know that aid has the potential to do a lot more good than it does, and we believe that it is still worthwhile to help struggling people as best as we can in the short-term while encouraging practices that support long-term growth. Even if it doesn’t prop up economies for years to come, aid really does change lives in the present, and we want to make sure governments, donors, and people like you are positive about the impact that aid money can have.

We are also huge nerds who go into the research business because we think it produces some really elegant experiments and gives us the opportunity to make randomization jokes all day long with people who won’t judge us. And we like the fact that research works. We've done it with deworming. We're doing it with chlorine dispensers. And Lord willing, there are a lot of other innovative programs out there that are going to find a lot more people because of research like this.  

Happy Global Handwashing Day!

As if you didn't already know today was Global Handwashing Day. Ha ha!

As a leader of a project that puts a huge emphasis on encouraging proper handwashing behavior here in rural Kenya, I'm proud to say that the Kenyan Ministry of Public Health elected to hold its national Global Handwashing Day celebration right here in Busia, to acknowledge the gains seen in hygiene behaviors and the dropping diarrheal disease rates in our province. This means we had the privilege of having 15,000 Kenyan school children and the Kenyan Public Health Minister descend upon our tiny town for five hours today, making presentations, giving speeches, singing songs...until the Minister decided five hours in Busia was quite enough for her, thank you very much, and jetted back to Nairobi several hours ahead of schedule. (Also yes, there was actually a competition to see which primary school could come up with the best handwashing song. The clear winner, in my eyes at least, was the class from Segere that educated all of us on the health benefits of handwashing by chanting all the diseases that could be prevented by proper handwashing behavior: "Cholera! Typhoid! Influenza! Measles!" They might have gotten beat by the class that set their song to a complete step routine...if they hadn't also done the whole thing as a round.)

But seriously guys, handwashing is, like, really important. According to figures from the World Bank and UNICEF, washing hands with soap at critical times (after going to the bathroom, before eating and cooking, etc.) can reduce diarrheal disease by 45% and acute respiratory infection by 30%, and can increase newborn survival rates by up to 44%, making it more effective than any single vaccine in terms of the number of infections prevented! For those of you who are still awake after that sentence, here is an exclusive look at one of the ways WASH Benefits, my project, is trying to improve the health of children in rural Kenya. Each of these "tippy tap" handwashing stations costs less than $2 to build and can be constructed entirely from materials available in any Kenyan village. I suspect you may have to settle for Home Depot.

Action shot!

Obviously, disease prevention is a lot more difficult than handing out some cans, poles, and string. Getting people to change their behavior, to invest in soap, and to keep their stations in good working order is a tremendous challenge, and a lot of my work so far has been geared toward facilitating that type of behavior change. So far, though, they've been a big hit (I hear that tippy taps are going to be a hot new lawn feature next summer--here's your chance to beat the curve.) More info is available at the official website of Global Handwashing Day. If you go to their "Resources" page, the top two articles were both written by professors on my project. No big deal.

I hope you all take time to wash your hands many times today, and to remember that on this day, countless kids around the world are learning to keep themselves and their families healthier, pledging to practice better hygiene in their homes and schools, and singing about diarrhea at the top of their lungs.