Emily's Worldview

Sam’s words next to arrows, my responses underneath. Omissions marked with ellipses.

> So, first, I think you're merging a lot of what I said with a lot of
> other arguments which I'm not making (or not trying to make,
> anyway). I'm not saying that our entire strategy should be to
> concentrate on making good arguments,or to focus on macroeconomic
> stuff. I'm saying that both of these need to be part of the
> strategy, and that it's a mistake to leave them out just because
> you're not seeing them as particularly effective. First of all,
> they're difficult to measure -- they kind of form the baseline for
> all other forms of action. I think that you'd see the world in a far
> worse place today if NOT for, especially, the huge economic
> incentives, etc. And I'm not going to be able to justify this based
> on any concrete examples; I'm at a huge disadvantage here. By
> showing failures of specific programs which try to help economically
> (rather than taking the health problem head-on), you're mentioning a
> lot of specific programs which were set up foolishly. I don't think
> that this speaks in any way to whether the approach in general is a
> good one; it's akin to "sex education is foolish because teaching
> children about abstinence has not decreased AIDS transmission." I
> never made the argument that we should be subsidising American
> farmers as a way to affect hunger in Africa, and I never asked for
> the "status quo".


You are saying that we have to maintain our credibility by making "good" arguments or no one with money is ever going to listen to us. That's what I'm responding to. I think a lot of development-as-usual projects are worse than ineffective: in the case of food aid and a lot of economic development projects (sweatshops, environmentally destructive "development" projects), they're actively detrimental. And the programs I was talking about are not "set up foolishly"; my point is that they're exactly the type of programs you will always get if you a) wait for the interests of the powerful to coincide with the needs of the poor and b) think that because people are poor, actions to promote their well-being should be held to a low standard.

Your argument is that as advocates we not make higher-order, "unreasonable" demands on the powerful because it destroys our credibility. Our strategy under your plan, therefore, would be to only advocate for the most feasible interventions and those that are most likely to line up with what the rich feel like doing. My argument is that as advocates we should work in the near-term for progressive realization of what we want but do it in the broader framework of a call for social justice which includes all the stuff that is in all those meaningless UN declarations which I already conceded should not necessarily be called rights. But, I still think we need some framework that puts those economic/social considerations, and the interests of the poor, at the forefront.

My argument was that, merely because a strategy is
> mis-used, we shouldn't necessarily scrap the strategy; not that we
> must pursue that strategy to the exclusion of others, or that we
> should blindly follow an existing, failed structure. As this whole
> practice of throwing our economic weight around to micromanage living
> crises is incredibly new (at least to me, it seems like it's only 20
> years old at most), it's natural that we haven't gotten it right.
> Even I can clearly see problems with implementation, but I feel that
> abandoning these overall strategies because they have not yet been
> effective (btw, see my other favorite argument that NO program is
> ever going to be effective unless it's subject to invasive monitoring
> and the proper incentives for performance) is almost the same as
> saying "well, Africa isn't helped much by MONEY, clearly, so let's
> try the approach of withdrawing all foreign aid." (analogies don't
> work as well when they're on the same general topic, but I hope that
> made sense) I don't know enough to state with any certainty that
> economic measures have been ineffective because they have been
> haphazardly organized and trivial in scale next to what would be
> necessary, but I strongly suspect that this is their primary failing,
> for which the measures themselves shouldn't be blamed.

I'm not arguing against the strategies, I'm arguing against the logic that underpins them and results in the bad strategies being chosen and their implementation being so lame. If we sat down and looked at it and the status quo was really the best way to help the poor _regardless of the interests of the rich and powerful_ then I would advocate for it loud and lustily. What I am saying is that we need a framework for policymaking that makes it possible to pick strategies that actually help people instead of the current framework, which I argue, doesn't.

…The status quo is the last thing I'd ever argue for in
> just about any field, except possibly in French cooking, where people
> always screw it up when they try to modernize it. My entire point is
> a baby/bathwater one. In this particular way, I _do_ think you're
> … lumping a whole series of
> arguments together because they are occasionally made together and
> then attacking one in that group based on the insufficiency of
> others. Which is kind of the point I was trying to make with re-
> defining the question. It's not that looking at a problem in a
> different way is bad, it's that it's not addressing the question
> under consideration.
>
> [re-defining] "Public health experts recommended putting all the
> focus on prevention of HIV and treatment of opportunistic
> infections. ... Partners in Health started treating people with
> antiretrovirals at their clinic in Haiti and they showed that they
> could get high adherence rates and that people got better, and they
> did it despite the 'riptide of cost-effectiveness arguments'"
>
> That's not re-defining the question, though, that's challenging an
> assumption made by 'experts'. By re-defining the question, I'm
> talking about an argumentative (does that have two meanings? I mean
> 'relating to argument') tactic. I don't think anyone is more
> skeptical of 'experts' than I am; I think every field benefits by
> challenging the idiocy of the current way of thinking of things. I
> was trying to make the point (no doubt ineffectively) that it doesn't
> really make ANY point if you fail to address the one on the table --
> someone can always re-define a point away. (I like the example of
> the second-to-last panel in the last comic strip of this link: http://
> www.doonesbury.com/strip/oldglory.html ) I'm not in any way trying
> to say "don't challenge how things are being done."


Look farther up in that paragraph. Before advocates got involved it was all about how to manage and prevent HIV in Africa--we said that that was a ridiculous way to frame the problem when treatment existed. Okay, it's not as fundamental as asking "so why is Africa so devastatingly hit?" but it's an example of how reframing the public debate made stronger action possible.

And I don’t see any reason why asking the big questions is incompatible with taking immediate action. That's why you work for progressive realization + long-term vision. Like the organization I worked for in Tanzania. We understood that the children we were serving were suffering because of a lot of huge forces—history, social breakdown, growing inequality within their country, corruption, etc. and we understood that we weren’t providing them with the services that they deserved. But we saw that it was valuable for us to do what we could to make their lives better. I don’t really plan to spend the rest of my career moping around how global inequality is so terrible and unfair; we have to do what we can, but do it within a framework that makes it possible for the poor to get out from the bottom of the pile.

>…
> "I'm really against this idea that we should set a bare minimum and
> make sure that we achieve that and then in some rational future
> moveon to the next order of business."
>
> That's exactly what I'm arguing against. I don't think you CAN move
> on later and re-define the scope of rights. But again, you're
> equating rights and things we think are good. And I grant you that,
> within the Public Health and Human Rights arenas, the word has been
> largely re-defined beyond anything I would have thought of as a right
> -- perhaps to the point that we're actually thinking of different
> meanings. I just don't see something as a right merely because I
> believe someone deserves it, or because it's owed to someone. I
> think every government has the absolute, unquestionable duty to care
> for the poor and the sick; I think these are more important functions
> than guaranteeing the free practice of religion, but I don't think
> that their importance makes them "rights".
…
> OK, here's the point I'm trying to make in everything: we have to
> have levels of principles, each of which trumps the one before it, or
> everything becomes situational and pointless. I like the metaphor of
> the laws and the constitution… Like laws which we'd
> like to make, but which conflict with higher goals (I'd like to
> outlaw the Chicken Caesar Salad, but I know that would be wrong, even
> though that specific law would undoubtedly make the world a better
> place), I believe that rights are something not to monkey with out of
> a desire for a result, and I believe that disingenuous arguments are
> bad even if they are convincing, effective, and improve people's
> lives. The ends can't justify the means in a policy sense, ever. I
> think that's just about the most important principle on earth, maybe
> even outranking "be nice to each other".

I feel you, my brother. I understand your arguments. But I don't agree. Ends matter and the people who control the means have their eyes on the ends, so we have to too.

I've been having an interesting email exchange with my friend, "Sam". "Sam" has been thinking a lot about human rights and global justice lately, and agreed to let me excerpt her emails anonymously, and my response. I marked deletions with ellipses.

Sam says;

My basic point about the Human Rights world is that it trivializes
some of the most important issues on earth....It's like the "15
billion women are beaten every minute" campaigns. You exaggerate a
real threat, or you make it too sensational, and it hurts the
credibility of everyone addressing it, and it kills your own. If
it's something that's bad, the simple facts stand on their own better
than overblowing them. It's totally irrelevant that people who
already agree with you are "shocked, horrified"; it's incredibly
relevant that it turns off one person who is generally suspicious of
"liberal" claims…

There's the whole argument about subsantive vs. aspirational rights,
or civil/political vs. economic/social, or first-generation vs.
second-generation, or negative vs. positive, which are all basically
the same thing, and one which I could have for months… Of course, I think that this is a re-definition of the word "right" to begin with; there's something
questionable about the logic of a right which isn't actually
exercised anywhere, and something even more questionable about the
idea of a "right" which can't be defined (aspirational rights). So,
first, we're saying that the right to be free of cruel punishment is
on par with the right to organize a labor union... who genuinely
believes this? Second, if we re-define "right" as something we
really, really WANT everyone to have, it loses its meaning entirely.
Third, if we WANT something to happen, the worst possible strategy is
to concentrate efforts on toothless demagoguery, trying to attain
some sort of moral high ground -- fine, so we've gotten a bunch of
countries/people to agree, despite the fact that they don't really
BELIEVE it, that something is unassailably correct; now we can start
the work that we actually intended in the first place, but with the
huge moral force of a bunch of countries merely paying lip service to
something?

Concentrating on a "rights" framework seems to me the ultimate in
wasted effort. Generally, I prefer the long-term game in trying to
attack huge issues. But creating documents by which no one feels
morally bound devalues the power of treaties in general and causes
people to start distrusting international institutions which depend
entirely on universal acceptance. I've come through this
international law thing with a deep skepticism of the UN. If I have
reversed course this much, you can bet that there's not a prayer in
the world for the UN, or any of its bodies, gaining any moral force
with any of the world who was already suspicious. People lump
themselves easily into camps, and this is driving people in droves
into the Bush camp. Hell, they make better arguments these days;
their conclusions may be wrong, and their logic may be disingenuous,
but it's become less disingenuous than the logic on the left, because
we've stopped even trying to be logical. We're hell-bent on making
an absolutist point, and going for the emotionally appealing image,
and exactly the sort of fear-mongering, alarmist, irresponsible crap
that they've always accused us of (wrongly, in the past, rightly now)
in the first place. And I think this all boils down to righteous
indignation and the unwillingness to be self-critical.

…I guess my
point is that the people on the "right" side end up doing more damage
to their cause by ineffectively pursuing it than people on the
"wrong" side do through direct attacks.

You re-frame the question as "why are resources for the health of
poor people limited?". I think that this is one of those arguments
which is best made as a separate point entirely from the ideas of
cost-effectiveness and sustainability, etc. Sure, these buzzwords
are largely crap. But I think that cost-effectiveness IS an
important point, because our resources ARE limited -- and not just
for poor people. And our resources will always be limited, no matter
how much we change things. So, yeah, your question is more
important, but it defines away the nitty-gritty as irrelevant by
asking that it be answered first. … I think that re-defining the question is
one of those things that, while it may make the most sense, detracts
from the force of an argument. NOT that I'm claiming you shouldn't
use that when talking to me; please don't take it that way. But I
think it's the surest way for the good guys to lose an argument in
the public arena, because it's been over-used to the point of
absurdity…


Emily says;

…I understand the arguments you are making about strategy in the field of
international advocacy for the shafted. And I think we do agree on
the fundamentals, like that the public health/UN infrastructures are
part of the same system that puts people in such a bad position. And that overclaiming
dangers/tragedies/outrages is counter-productive, particularly at the
point where everything is so fucked up already. I'm pretty agnostic
on the rights thing, and pretty uneducated about it…but maybe will make a
tepid argument for them below. And obviously I agree that we have to
work with the big jerks of the world and get them on our side. Oh, and
I agree that protesting globalization or the WTO as a whole is dumb.

But I still fundamentally disagree with the idea that our strategy as advocates
should be to spend
all our time making good arguments, to get the people with the money
"to sway slightly in an egalitarian /
altruistic kinda way", presumably, when being egalitarian/altruistic
happens to line up with their own interests. You're making an
effectiveness argument, but I just don't see any evidence that that
strategy has been effective in making people's lives substantially
better. To me, your strategy is the status quo—people doing good when
it suits them, not when it doesn't—and not only does it result in a
lot of direct screwing, like unfair international trade rules,
predatory investment, child sexual exploitiation, but it also results
in a lot of really ineffective aid. So when there is famine in Niger
we pay American farmers a fair price for corn, pay an American
shipping company a no-bid rate to ship it, and 6 months later, after
the rains have come and the farmers have harvested, a whole lot of
free corn arrives and screws up the market, setting people up for next
year's famine. And the thing is, that's the kind of aid we feel good
about.

I would argue that at its most benign, what your strategy gets us is a
lot of donor-driven, vertical programs that may have a moderate impact
wherever they are targeted, but that end up either straining or
undermining the government and other aid projects in the area…

You say that "re-defining the question is
one of those things that, while it may make the most sense, detracts
from the force of an argument" but I think HIV treatment is a perfect
counter-example. As advocates, people told us we were impractical for
asking the question, "Why should tens of millions of people infected
with HIV be sentenced to die when treatment exists?" 8 years ago, the
head administrator for USAID told reporters that antiretroviral
therapy would never be feasible in Africa because Africans can't tell
time. Public health experts recommended putting all the focus on
prevention of HIV and treatment of opportunistic infections. But
those tens of millions of people were beyond the point of prevention,
and when you have HIV, treatment of OIs only makes you feel a little
better and then you die. Partners in Health started treating people
with antiretrovirals at their clinic in Haiti and they showed that
they could get high adherence rates and that people got better, and
they did it despite the "riptide of cost-effectiveness arguments"
(that's Paul Farmer, my hero). Other advocates used that evidence to
make their arguments and now, just a few years later, there are
literally billions of dollars for HIV treatment for poor people. If
we as advocates had spent all our energy asking for palliative care
for sick people and jumpropes for orphans, that's what we would have
gotten, and Bush would have been just as self-congratulatory as he is
now; it would have been just as much in his interest as the money he
put up for antiretroviral therapy.

That logic also justifies supporting a lot of really bad policies.
Food aid in the status quo is just one example, but so are malaria programs
that provide cheap drugs in regions where the malaria is already
resistant to the cheap drugs. I want to give an example from the
research I am working on. So, right now for the prevention of mother
to child transmission of HIV in Africa, they are implementing 2-dose
nevirapine. The mother takes a pill when she goes into labor and the
baby gets a dose within 72 hours of both. It's cheap and it's easy
for the mothers to do themselves, and when implemented properly, it
cuts the rate of transmission during delivery in about half. But in
the US and other developed countries, the standard of care for years
has been a short course of combination antiretrovirals or at least AZT
for a month before delivery. This is harder to do, and it's more
expensive, but mother to child transmission in the US is now virtually
0. So what should our strategy be? Should we be scaling up the easy
intervention because it is the most feasible and realistic and be
satisfied that even if we had 100% coverage about 30% of the babies
will still get infected? Or should we be working to provide African
mothers with the same standard of care that American mothers have been
enjoying for years? I don't think that asking that question
undermines the current program, and I think it provides a better
direction for the future.

And I don't think a more expansive/fundamental view is impossible
because I think we are seeing a change in the way the public debate is
framed now. Look at Warren Buffet—he didn't give 34.7 billion dollars
to one of [those] business-as-usual
NGOs; he gave it to Gates because they are one of the organizations
that can actually change the world because they are willing to invest
in what critics say is impractical or too expensive.

I think it is more effective to advocate for what we want in the long
run, and negotiate for what is required in the meantime. So let's not
limit ourselves to saying that we want everyone in Kenya to get a
grade 6 education, let's say that everyone deserves access to a
complete education and start with the primary schools. It's true that
we need money to do what we want to do, but that is in the short term.
If we don't have and push our long-term vision, whose plans for the
future will prevail.

You say, "If we re-define "right" as something we
really, really WANT everyone to have, it loses its meaning entirely."

I just don't see why. ...Just because children don't have schools to go to
doesn't mean they don't have a right to education, or because there
are no hospitals, women don't have the right to give birth safely.
I'm really against this idea that we should set a bare minimum and
make sure that we achieve that and then in some rational future move
on to the next order of business. There's no waiting for some day
when no one is being tortured so we can start talking about housing.
Let's not confuse advocacy and declarations with action (ahem, UN) but
let's build our policy now around a set of ideals for the long-term
future… South Africa's model is "progressive realization of rights" or something like that, and I think that's what I'm for.

I'm always getting disqualified for donating blood in the US for silly reasons; for being anemic, for having a cold. I've been summarily dismissed the last few years for having spent too much time in Africa, which apparently puts me into some kind of relatively high risk group for HIV.

Here in Western Kenya, I am in a relatively low risk group, but when I tried to donate today on my lunch break (at the state of the art transfusion center that shares our compound), I was rejected again. This time it was my malaria prophylaxis, but the lady was nice about it: "Come back and donate sometime when you are not on drugs."

I would like to take this opportunity to introduce the cast of characters at the house where I am staying. There is Florence, my “host mother” (she is only 27), who has a bubbly laugh and is very fun-loving. There is Peter, the father of the house, who is a nice guy who spends a lot of time making exasperated sounds at the TV news. The oldest child is seven-year old Sandra, who is quiet and sweet and falls asleep like a person falling off a cliff. There is her younger brother, Francis, who everyone calls Uncle. He is a typical active 5 year old boy who can often be seen kicking a soccer ball around the house, putting his fingers in the communal food dishes, throwing trash on the floor, rifling through my things, yelling, and being told to stop whatever he is doing. In addition to the nuclear family, there is the housekeeper from the village; there is Evelyn, a 14 year old girl who goes to school during the day and does huge amounts of housework in the evening (she is somehow related to somebody in the house); there is Odipo, another relative, who is a student about my age whose spine is twisted into knots by a case of childhood polio. Then there is a rotating cast of 1-3 other unknown relations who appear for some reason, stay for a few days, and then leave without notice.

The 9+ of us sleep in three bedrooms with four beds total, we gather around the table for dinner and make the kids share chairs with adults, we swat mosquitoes in the evening, take turns playing soccer with Uncle, watch World Cup games, laugh, make noise, and sometimes get angry at each other. At times I get a little jealous of my friends here who have their own rooms and get to go to sleep when they want to, eat what they want to, and avoid the minor eruptions that take place whenever people live in close quarters with each other. But overall, I feel very lucky to have been invited to share the life of this family, and I find that I grow more tolerant of the annoying parts over time, not less.

The work is going great, and if anything I am overwhelmed by how much more I am going to be able to do than I expected. I spent a week in the big hospital in the relaxed town of Kisii, poring through reams and reams of inconsistently kept, handwritten patient registers. I can’t say that the large amounts of data entry this project requires are particularly thrilling, but I do get some geeky kicks out of what the analysis is turning up. I have to make a 10 minute presentation of it all in about two weeks, in addition to a clutch of reports, so I’m feeling pressure to figure it all out and boil it down quickly.

But, the real fun has been on the weekends. Two weeks ago two friends and I woke up late one Saturday in Homa Bay and headed for Homa Hills. This task was complicated by the fact that we had missed the morning’s boat and the once daily minivan, so we hung out by the water’s edge until somebody gave us a reasonable price to get across the bay to where the hills loomed. The boat dropped us on a shore where people were washing their dishes and their children in the lake’s water. We started up the only road, passing nothing but farms and fields and friendly people carrying water, firewood, babies. With every step, the view was more beautiful, as we could see more of the silvery lake, ringed with pale blue hills, more of the fields we had already passed, more of the red road snaking behind. Eventually we decided to turn off the main road to head up the steep part of the hill. We asked around and started up a path between the fields, which we lost, then found, then lost again. As we were trying to figure out which way to try next, a very pregnant woman came scampering up and proceeded to lead us up the hill, on what might have been a path if the millet hadn’t been fully grown and ready to harvest. As it was, it took a lot of crashing around and picking our way through downed stalks until we came out on a little hump that brought us the most beautiful view yet of the fields, the silver bay, and the mountains in the distance. Much farther up the hillside, children tending herds of animals whooped and yelled to each other.

Then this last weekend, five of us went to Kakamega Forest, a national preserve that protects some of the last remnants of the rainforest that used to stretch across the country. After an irritating hassle at the gate, we were immediately mollified when a red-tailed monkey crashed through the trees above our heads. We spent the next two days wandering the forest’s trails, marveling at iridescent butterflies, enormous snails, strange birdcalls, troops of colobus, red-tailed, and blue monkeys. Despite our combined intellectual prowess, we did not plan well for the afternoon rainshower and ended up running around looking for our cabin in the midst of a soaking storm, with two umbrellas and one jacket between us. On the second day, we woke up while it was still dark and charged up a hill with a lookout tower. As the sun came up, mist moved through the trees, birds and monkeys called, and we could even hear drums from a church in a neighboring village. I was overwhelmed. The guide told us about all the amazing and wonderful species of animals that the forest kept well-hidden; he told us that the two little snakes we had spotted the day before were about the deadliest in the world (10 minutes, he said, and you can see your leg disintegrating; 20 minutes and you’re dead) and on our way back to the cabin, he identified two sets of tracks: serval cat and pangolin (worth looking up).

Later that morning, we missed a turn and ended up on a six hour hike through the dripping forest, with little food or water and less than 100% certainty that we were heading out of the forest and not deep into a neighboring preserve. At our tiredest and most footsore, after we finally found our way and were trudging up a long murderous hill, we came upon a troop of baboons, which included a tiny baby with its ears sticking out, who looked back at us calmly before moving into the trees. Fortunately, I was with a group of three guys (our fifth companion left the day before) who kept laughing throughout the whole ordeal, and even held up well when our ride to town from the park gate ended up being a school bus carrying an entire, very excited, girls soccer team. For once, I was not the star attraction. Despite the fact that every time I spend a day with these guys, I miss lunch, have to share my water, and end the day sore, scratched, sweaty, filthy, and usually bleeding, and despite the fact that they chose to wake me up for our sunrise hike with a farting contest, it has been on our adventures that I have felt the most alive and the most like myself.

I know that I am here to work on HIV and to learn about health care, and doing that has been rewarding in many ways, but this country is beautiful end to end and I wish I had time to see every part of it. I guess it’s a beautiful dilemma—feeling overwhelmed by all the amazing things you wish you could be doing at once.

One of the Wise Old Guys of public health, who addressed us early in our first year, reminded us to always see "the faces behind the graphs". I was crunching numbers just now and got one, .208, that made me pause. For the average woman who attends antenatal care at one of the nearby district hospitals, who is 25 years old and 27 weeks pregnant, who is thinking about the new life inside of her, and the changes in life ahead of her, who agrees to a simple HIV test in addition to her height, weight, and blood pressure, who sits across from the white-suited nurse and waits for the test results to show, that is the probability of receiving a death sentence, the probability that the drop of blood from her fingertip will turn the test positive. The calculator clicked, and I saw her face.