Aid Watch Rerun: Nobody wants your old shoes: How not to help in Haiti

NOTE FROM THE EDITORS: Over the holidays, we'll be publishing reruns of some of our posts from the first 2 years of Aid Watch. This post originally ran a week after the Haiti earthquake, on January 16, 2010. The following post is by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk.

Don’t donate goods. Donating stuff instead of money is a serious problem in emergency relief. Only the people on the ground know what’s actually necessary; those of us in the rest of the world can only guess. Some things, like summer clothes and expired medicines are going to be worthless in Haiti. Other stuff, like warm clothes and bottled water may be helpful to some people in some specific ways. Separating the useful from the useless takes manpower that can be doing more important work. It’s far better to give money so that organizations can buy the things they know they need.

Some people like to donate goods instead of cash because they worry that cash won’t be used in a way that helps the needy. If that’s you, I have two points. 1) Why are you donating to an organization you don’t trust? 2) What’s to stop them from selling your donated item and using the money for whatever they want?

After Hurricane Mitch in 1998, Honduras was flooded with shipments of donated goods. They clogged ports, overwhelmed military transport, and made it nearly impossible for relief agencies to ship in the things they really needed. Those donations did harm, not good. Expired drugs had to be carefully disposed of. Inappropriate donations had to be transported away and discarded. All of this wasted time and money.

Don't go to Haiti. It’s close to the US, it’s a disaster area, and we all want to help. However, it’s dangerous right now and they don’t need “extra hands”. The people who are currently useful are people with training in medicine and emergency response. If all you can contribute is unskilled labor, stay home. There is no shortage of unskilled labor in Haiti, and Haitians will be a lot more committed than you are to the rebuilding process.

If you are a nurse or physician, especially with experience in trauma, and you want to volunteer, email Partners in Health – volunteer@pih.org – and offer your services. Or submit your details to International Medical Corps. They’ll take you if they can use you. Do not go to Haiti on your own, even if you are doctor. You’ll just add to the confusion, and you’ll be a burden to whoever ends up taking responsibility for your safety.

Don’t ignore rebuilding. The physical damage done to Port au Prince is going to take a long, long time to repair. The human consequences will have a similar slow recovery. Haiti will still need our help next year, and the years after that. It is going to take more than just a short-term infusion of relief money. Give your money to organizations that will be in Haiti for the long haul, and don't forget about Haiti once the media attention moves on.

What Hillary’s cookstoves need to succeed

This post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. Yesterday, Hillary Clinton announced a new $60 million initiative to help 100 million households adopt clean and efficient cookstoves and fuels by 2020. The Global Alliance for Clean Cookstoves is a public-private partnership that includes the US State Department, the UN Foundation, the World Food Program, Royal Dutch Shell, the World Health Organization, and the US Environmental Protection Agency, among others.

Secretary Clinton, who made the announcement on the opening day of the annual Clinton Global Initiative meeting, made a good case for the importance of cookstoves in the lives of women and families. She framed it as a global health issue:

Exposure to smoke from traditional stoves and open fires – the primary means of cooking and heating for 3 billion people in developing countries – causes almost 2 million deaths annually, with women and young children affected most.  That is a life lost every 16 seconds.

But here’s the thing. Improved cookstoves aren’t a new idea. They’ve been kicking around international development circles since the 1940s. The Magan Chula stove, for example, was introduced in India in 1947. Never caught on before. Why would this effort be different? Why would it work this time?

The major flaw in previous cookstove efforts was focusing too much on good design from a designer’s perspective, and not enough from a user perspective. The improved cookstoves were technologically sophisticated and environmentally friendly. But they weren't comfortable for the women cooking on them, and they required changes in cooking methods, some of which made the food taste different.

In the kind of patriarchal societies that keep women tied to stoves and kitchen responsibilities, women don't have a lot of autonomy for decision-making, especially not about major household issues like a new stove. Many of the benefits of better cookstoves don’t directly impact the families who use them. Decreasing the environmental impact of a stove has no obvious effect on its owner. And indoor air pollution isn’t an obvious problem to the people who live with it – they don’t necessarily connect their illnesses with the stove that causes them, and when everyone lives the same way, there is no comparison to demonstrate the link.

Most importantly, using a new kind of stove means cooking differently. That’s a huge lifestyle change. It’s hard for the women who are doing the cooking, and it’s hard on their husbands and families, who may not like the new kind of food that results.

If this new effort is going to avoid the mistakes of its predecessors, it needs to do a few vital things:

• It needs to get as much input as possible from the people who will actually use the stoves. The stoves will need to be as much like existing stoves as possible, to minimize the change in cooking style required to use them. In particular, women need to be able to cook traditional foods that are appealing to their families. Listening to the women who’ll cook on them is the best way to do that.
• It needs to produce affordable stoves and consistently distribute them. Price is a big barrier to use of better cookstoves, since the benefits aren’t immediately obvious. The stoves need to be cheap enough that families can buy them with a minimum of savings or debt. Since they won’t last forever, there needs to be a steady supply of available improved stoves. That means building a structure for production and distribution, not some kind of one-off stove airlift.
• Finally, it will need to market the stoves intensely. Since the benefits to getting a new stove are obvious, and the problems aren’t, they’ll need to really sell these stoves. Women, and their families, will need to be convinced of the benefits. That will require a lot more than a dry brochure or an earnest slogan.  It will need actual ads, with an advertising strategy behind them.

Is Impact Measurement a Dead End?

This post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. We’ve spent the last few years watching the best donors and NGOs get more and more committed to the idea of measurable impacts. At first, the trend seemed unimpeachable. International donors have spent far too much money with far too few results. Focusing more on impact seemed like the way out of that trap.

But is it? The last couple of weeks have seen a spate of arguments from development thinkers rethinking this premise.

Steve Lawry at the Hauser Center, argues two main points against excessive focus on impact evaluation. The first is that it stifles innovation by keeping NGOs from trying risky new things. But I think that the problem is an institutional culture that doesn’t allow for failure. By allowing NGOs to fail and learn from failure, innovation is encouraged.

His second point is more interesting: “Many real-world problems are not easily described with the kind of precision that professional mathematicians insist upon. This is due to the limitations of data, the costs of collecting and analyzing data, and the inherent difficulties of giving mathematical expression to the complexity of human behavior.” This strikes me as very true. At what point are we expecting too much from our impact assessments?

In the same vein, the fascinating Wanderlust blog just ran a post about Cynefin. Cynefin is a framework for understanding systems. It categorizes systems into four subsets: Simple, Complicated, Complex or Chaotic. Chaotic systems, the author argues, can’t be evaluated for impact using standard measures. He states that “In a Chaotic paradigm, there is relatively little difference likely to occur in quality between a response that is based on three weeks’ worth of detailed analysis and one that is based on the gut reaction of a team leader…”

The Center for Global Development just published a paper by former USAID administrator Andrew Natsios. Natsios points out that USAID has begun to favor health programs over democracy strengthening or governance programs because health programs can be more easily measured for impact. Rule of law efforts, on the other hand, are vital to development but hard to measure and therefore get less funding.

Now we come to the hard questions:

If we limit all of our development projects to those that have easy metrics for success, we lose a lot of programs, many of which support important things like rule of law. Of course, if they don't have useful metrics, how do we know those programs are supporting the important goals?

And how meaningful is impact evaluation anyway when you consider the short time frames we’re working with? Most development programs take ten years or more to show real impact. How are we supposed to bring that in line with government funding cycles?

On the other hand, we don't have a lot of alternatives to impact evaluation. Impact is not unimportant just because it’s hard to quantify at times. We can’t wish that away. Plenty of beautifully designed and carefully implemented projects turned out not to have any effect at all. For example, consider what we’ve learned from microfinance impact evaluations. Microloans have a positive effect but not the one we expected.

It’s a standard trope of this blog to point out that there’s no panacea in global development. That’s true of impact evaluation, too. It’s a tool for identifying worthwhile development efforts, but it is not the only tool.  We can’t go back to assuming that good intentions lead to good results, but there must be room for judgment and experience in with the quantifiable data.

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UPDATE: This post was edited to correct an attribution error in the third paragraph - Eds.

A warning from Tajikistan

The following post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. A polio outbreak is underway in Tajikistan. 12 people have died of the diseases since March. 32 cases of polio have been confirmed, and 171 cases of acute flaccid paralysis (a signal of possible polio) have been identified. That’s a full-fledged outbreak in a country with an 82% vaccination rate. Until this January, there hadn’t been a polio case in Tajikistan for 13 years; Tajikistan was certified polio-free in 2002.

Tajikistan should simply not be seeing a polio outbreak – an 82% vaccination rate is enough to achieve herd immunity and protect even the unvaccinated. And we know this is not one of the rare vaccine-caused outbreaks because the WHO has done genetic analysis on the polio strain – it is wild polio.

Something has gone wrong in the health sector in Tajikistan. There are several ways that the health system could fail on vaccination. Vaccine records could be inaccurate, causing unvaccinated children to be missed by the system. Or the cold chain is not being maintained and the vaccines are losing effectiveness – the oral polio vaccine is especially vulnerable to warm temperatures. Whatever happened, it’s a sign of health system weakness and the Ministry of Health of Tajikistan will need support to improve it.

This outbreak calls into question the disease eradication approach to public health. Tajikistan has shown genuine commitment to polio eradication and that commitment has not been enough. Without a health sector strong enough to ensure effective vaccination coverage, a single-disease focus just doesn’t work. That idea is slowly being accepted. Eradication proponent Bill Gates called the eradication approach into question in his annual letter, mentioning slow progress to date in Nigeria.

If disease eradication is not the key to promoting global health, what is? Successful immunization against dangerous childhood diseases requires the same basic health sector resources as fighting HIV, protecting maternal health, and preventing chronic illnesses: a sufficient number of trained staff, useful data and the ability to act of it, health infrastructure, and effective financing methods. Support for those resources therefore strengthens a nation’s health as a whole.

Moving to a health systems approach for supporting global health will maximize the impact of global health spending. Every dollar spent will battle more than one disease. A broad systems approach also directly supports the goals of disease eradication by making sure that health staff are available, and trained, to provide vaccinations, and that the logistical system is in place to keep vaccines cold.

A systems approach will also support the structures needed to maintain disease elimination. Even after polio has been eliminated from a region, vaccination for the disease needs to continue as long as it still exists in human patients anywhere. And surveillance is necessary to watch and prepare for new outbreaks of the disease, like the one we are seeing in Tajikistan.

Tajikistan’s polio outbreak is a warning sign. You can’t eliminate a disease without also building a health system that ensures the disease stays eliminated.

The Plumpy’Nut dust-up: Nutriset’s side of the story

The following post was written by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. Plumpy’Nut is a lifesaving Ready-to-Use-Therapeutic-Food that was developed, and patented, by a French company called Nutriset. An American NGO and company have brought suit against Nutriset in an attempt to break the patent. I wrote about the basics of the situation in a previous post.

That post brought up more questions than it answered. In an attempt to cast some light on the situation, I talked to two people from Nutriset: Remi Vallet, and Adeline Lescanne, by phone and via email. The answers below cover my communications with both of them. Mr. Vallet is the Nutriset communications officer and Ms. Lescanne is Nutriset’s deputy general manager.

The Nutriset View:

1) What’s the deal with nutritional autonomy?

When Nutriset was founded in 1986, its mandate was “feeding children.” That changed over time – the current mandate is contributing to nutritional autonomy. “Nutritional autonomy does not mean nutritional autarky,” says Vallet, “We don’t want North Koreas. But local production benefits the local economy.” Rather, communities should be able to identify their own nutritional needs and access to what they need to meet them. This means that Plumpy’Nut should be made as close to the place of need as possible. Most Plumpy’Nut ingredients are available in Africa, especially peanuts and oil.

2) Won’t restricting Plumpy’Nut to local production drive up prices and limit access to Plumpy’Nut?

Local production is not necessarily more expensive than international production; transportation taxes are high and so are import taxes. In addition, small local NGOs may not have the capacity to handle a large internal procurement of Plumpy’Nut, but they can work with a local manufacturer.  Importing Plumpy’Nut can also face political opposition, such as what we saw in India. Local production avoids that problem.

3) How does Nutriset’s patent support local production?

It’s much more difficult to set up a factory in Africa than it is in the US. African businesses have trouble accessing capital and navigating bureaucratic obstacles. The patent allows Nutriset to work with local partners and protect them from international competition while they develop. US producers would use subsidized raw materials, and overwhelm local producers.

My take on this:

I came away from my discussion with Nutriset convinced of their good intent and unconvinced of their logic. This is clearly not a case of an evil corporation profiting from hungry kids. Unfortunately, I don’t think that matters.

Nutritional autonomy is the heart of Nutriset’s case for their patent, and I just don’t get it. I spent quite a while talking to Nutriset, but I still don’t see nutritional autonomy as a justification for the Plumpy’Nut patent. It seems to me that Nutriset could support local level nutrition through methods more effective than the Plumpy’Nut patent. For example, political opposition to imported food is not immutable; Nutriset could advocate for governments to accept the product. And if local production is no more expensive than international production, it won’t make much difference if factories take longer to set up in Africa.

Nutriset is trying to argue everything at once, here, and it doesn’t hold. If locally produced Plumpy’Nut is cheaper, more accessible to small purchasers, and less taxable, why exactly does it need a patent to protect it?

Dropping Haiti’s debt = sending old shoes

The following post is by David Roodman, a research fellow at the Center for Global Development (CGD) in Washington, DC. Last week my colleague Michael Clemens blogged in this space about the “The best way nobody’s talking about to help Haitians.” So as a complement, here’s what I think is the worst way that everybody’s talking about to help Haitians: cancelling Haiti’s debt.

I am not suggesting that Haiti’s foreign creditors should stick to their guns in order to teach the country a lesson about the sanctity of international debt contracts. Canceling or reimbursing Haiti’s debt payments over the next, say, five years, just as was done after the Asian tsunami, would make eminent sense. That would constitute debt relief but would not require debt cancellation.

Why not just cancel the debt outright, as the One Campaign, the Jubilee Debt Campaign, and Oxfam have demanded?

• The benefit would be low. Most outstanding loans to Haiti are repayable over 25–40 years and charge 2%/year or less in interest. So while the face value of Haiti’s debt is impressive—some $1.25 billion, not counting the $114 million in new IMF credits—the debt service over the next few years will be tiny. The IMF projects (table 7) the cost at $18 million for fiscal year 2009/10, rising to $34 million in 2011/12. Even those figures are high since the U.S. government is paying the $9 million/year interest on Haiti’s loans from the Inter-American Development Bank. Perhaps half the rest is owed to Taiwan and Venezuela, whose susceptibility to press releases from western NGOs is uncertain. So as little as $25 million in debt service may be in play over the next 3 years.
• Lobbying for debt cancellation crowds out other more important issues. Activist groups and politicians have limited time, staff, and political capital. Instead of fixating on dropping the debt, why don’t activists and politicians campaign to hold public and private donors accountable for avoiding the mistakes of past disaster relief efforts? Why don’t they take on textile interests in order to open our borders to “Made in Haiti”? Why not, as Michael argued, push for a Golden Door visa that would allow at least a few tens of thousands more Haitians into rich countries to work?

Reforming trade and migration policies, even getting donors to respond more effectively to disasters, requires confronting entrenched interests. But activists are at their best when they take on the tough fights. We owe it to Haitians to strive for what is best for them, not easiest for us.

A couple of weeks ago here on Aid Watch, Alanna Shaikh blogged under the title, Nobody wants your old shoes: How not to help in Haiti. Beyond the specific advice, she was voicing a big idea close to Aid Watch’s heart: so many aid efforts go awry because the giver decides what the receiver needs.

I fear that calls to cancel Haiti’s debt are the old shoes of political activism. Debt relief will hardly help Haiti recover from the quake. And in a crisis, if you’re not helping, you’re in the way. Let us do the equivalent in the policy realm of sending cash, by advocating reforms that will do far more to alleviate the suffering.

Dr. Lancet discovers hitherto unsuspected need for aid criticism

The Lancet has issued a severe editorial blast against the aid agencies (both official and NGO) for Haiti aid efforts. (Link requires free registration.) Alanna Shaikh points out where the Lancet is off base.

The Lancet knowledge universe has the perception "the aid sector" has "largely escaped public scrutiny." Who ever heard of any those obscure *&^%$#@ criticisms of foreign aid? That "coming age of accountability" crap? Sigh.

But, forget all that, here's a belated welcome to the concept of aid criticism, Dr. Lancet! Here's what you have already accomplished.

First, you analyze the political economy incentives of aid agencies:

large aid agencies can be obsessed with raising money through their own appeal efforts. Media coverage as an end in itself is too often an aim of their activities. Marketing and branding have too high a profile.

Second, you note these political incentives could cause some needs to be neglected and others not, with the unhappy result:

when viewed through the distorted lens of politics, economics, religion, and history, some lives are judged more important than others

Third, no matter what  aid can do and/or cannot do, you note coordination between agencies is (actually will always be) a disaster:

relief efforts in the field are sometimes competitive with little collaboration between agencies, including smaller, grass-roots charities that may have have better networks in affected counties and so are well placed to immediately implement emergency relief.

You're off to a promising start in so far having shown an impressive grasp of the obvious, Dr. Lancet! Welcome to the aid accountability movement!

Nobody wants your old shoes: How not to help in Haiti

The following post is by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. Don’t donate goods. Donating stuff instead of money is a serious problem in emergency relief. Only the people on the ground know what’s actually necessary; those of us in the rest of the world can only guess. Some things, like summer clothes and expired medicines are going to be worthless in Haiti. Other stuff, like warm clothes and bottled water may be helpful to some people in some specific ways. Separating the useful from the useless takes manpower that can be doing more important work. It’s far better to give money so that organizations can buy the things they know they need.

Some people like to donate goods instead of cash because they worry that cash won’t be used in a way that helps the needy. If that’s you, I have two points. 1) Why are you donating to an organization you don’t trust? 2) What’s to stop them from selling your donated item and using the money for whatever they want?

After Hurricane Mitch in 1998, Honduras was flooded with shipments of donated goods. They clogged ports, overwhelmed military transport, and made it nearly impossible for relief agencies to ship in the things they really needed. Those donations did harm, not good. Expired drugs had to be carefully disposed of. Inappropriate donations had to be transported away and discarded. All of this wasted time and money.

Don't go to Haiti. It’s close to the US, it’s a disaster area, and we all want to help. However, it’s dangerous right now and they don’t need “extra hands”. The people who are currently useful are people with training in medicine and emergency response. If all you can contribute is unskilled labor, stay home. There is no shortage of unskilled labor in Haiti, and Haitians will be a lot more committed than you are to the rebuilding process.

If you are a nurse or physician, especially with experience in trauma, and you want to volunteer, email Partners in Health – volunteer@pih.org – and offer your services. Or submit your details to International Medical Corps. They’ll take you if they can use you. Do not go to Haiti on your own, even if you are doctor. You’ll just add to the confusion, and you’ll be a burden to whoever ends up taking responsibility for your safety.

Don’t ignore rebuilding. The physical damage done to Port au Prince is going to take a long, long time to repair. The human consequences will have a similar slow recovery. Haiti will still need our help next year, and the years after that. It is going to take more than just a short-term infusion of relief money. Give your money to organizations that will be in Haiti for the long haul, and don't forget about Haiti once the media attention moves on.

What we talk about when we talk about aid: A plea for accuracy

The following post is by Alanna Shaikh. Alanna is a global health professional who blogs at UN Dispatch and Blood and Milk. One thing that seems to get lost in debates over aid is the idea that “aid” is not a monolith. People talking about aid may mean church-to-church shipments of used clothes, World Bank loans to build dams, money transfers from donor governments, or expatriate-run projects that aim to provide services or improve the ability of the host government to govern. This is sloppy, careless language. It gets in the way of actually talking about aid.

We’re never going to have a useful conversation about aid effectiveness if we’re not even talking about the same things. When you ask if aid “works” – are you asking if financial transfers from donor governments to poorer governments actually reduce poverty? Are you asking if specific international development projects can achieve defined goals like reducing child mortality? Are you asking if aid gets used for its intended purpose instead of being diverted into graft?

If we’re going to talk about work as important – and expensive – as international aid, the least we can do is use accurate language. So, here’s my suggestion. Let’s stop using the word “aid”. Just drop it from our vocabularies because it is making our discourse worse. If you’re talking about development projects, then say so. Use those exact words: international development project. If you’re talking about budget support to poor governments, say so. Church gifts? That would be charity.

Sure, it sounds crazy. But it sure wouldn’t make things worse, and it might make our discussions a little clearer. We have plenty of ways to talk about this that don't require a vague and unhelpful collective noun. Let’s use them.