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.

Score one for USAID

There's a lot to like about Rajiv Shah, tapped by President Obama in 2009 to head the US Agency for International Development (USAID). He's crazy young for the position (only 37), but he already has an MD from UPenn, a Master's in Health Economics from the Wharton School, and has studied at the University of Michigan and the London School of Economics. He's new, he's smart, and he represents an extremely refreshing change of  pace for an American aid system that has been, shall we say, an under-performer of historic proportions up to now.

Today, though, I specifically like his emphasis on innovation and rigorous scientific evaluation in development programs, which leads to more accountability, more fresh ideas, and more aid dollars being spent on programs with scientifically-proven impacts. In fact, Dr. Shah just announced the creation of a Department of Innovation within USAID to facilitate the funding and development of such programs.

But here's the kicker: when you want someone to take charge of an innovative new research-based development program, who do you call? Um, that would be my boss (previously shown accessing the internet from strange rural Kenyan places on this very blog). The new appointment doesn't change anything about my project or Michael's involvement in it, though. This could have something to do with the fact that the largest of the new department's first eight "Development Innovation Ventures" has been awarded to none other than Innovations for Poverty Action--IPA getting some major love from the Feds! (Not that we're surprised, mind you--Michael and Raj have worked on some pretty huge stuff together before, including a $1.5B global vaccine funding initiative.) 

More on this new department (and a mysterious, thinly symbolic picture of some colorful light bulbs) can be found here. Much more on how Dr. Kremer and IPA are driving this new model of aid and poverty alleviation will be coming this weekend. Exciting stuff, I promise.

On a completely unrelated note, this is kind of fun.

Random self-aggrandizing karate master analogy of the day

Thought from a day spent sick in bed with something that is not malaria (I got tested! It was negative! I'm using exclamation points because it is utterly shocking to me that I wasn't diagnosed with malaria at our local clinic despite the negative test--they tend to ignore trivial evidence like these so-called "blood tests", and usually default to that diagnosis for anyone who comes in with a body temperature a breath above normal, regardless of the other symptoms: "Hmmm...your x-rays show that your mild wrist pain is probably a fracture...but I'm going to go with 'malaria' on this one." Also I am happy that I do not have malaria, which is another reason. For the exclamation points.). Anyway, thought:

There are a lot of mosquitoes here. Like, a lot a lot. I don't particularly like mosquitoes, so I have been known to playfully snap at those that come buzzing within my range. I get a lot of practice. Like, A LOT a lot. At this point, I am basically the Mr. Miyagi of mosquito catching (I will also begrudgingly accept the title "Mr. Han of mosquito catching" from all you new-school, Jackie-Chan-loving types, but I won't be happy about it). I don't even need those wimpy chopsticks, I catch those suckers with just my index finger and thumb. Which is really gross once you get mosquito guts all over your hand, but Hollywood tells me that this ability to kill small flying insects is somehow extremely significant in my development as a human being and as a master fighting machine. With this new status, I have immediately set Mac to work on mindlessly repetitive home improvement projects in hopes that his newfound muscle memory will give him the skill and confidence to overcome his fears in a tournament-style showdown, culminating in a dramatic battle against the leader of the evil frog dojo. More on this story as it unfolds.