A new must-read site on Ebola and capacity building in Liberia

I don’t know who’s behind the site Codex Lector, but they’re writing about the Ebola response in Liberia through the lens of critical anthropology, and it’s fascinating.  Here are two posts on the World Bank’s descriptions of “traditional” healthcare practices:

[First post] The World Health Organization has a post about why the Ebola outbreak centered in Guinea, Liberia, and Sierra Leone has been so devastating that uses a fairly standard term for one of the aggravating factors of the epidemic in a section titled “Reliance on Traditional Healers”:

Traditional medicine has a long history in Africa. Even prior to the outbreaks, poor access to government-run health facilities made care by traditional healers or self-medication through pharmacies the preferred health care option for many, especially the poor.

Some day, I should like to go back to the United States, and tell someone who took the Hippocratic oath, and is proud of her storied alma mater, that it is so nice that she practices non-traditional medicine, lacking in a long history. In this dream, she would also be blessed that none of her patients ever go to a pharmacy to purchase medications over the counter when they feel ill.

[Second post] … Sometimes the World Health Organization post about the aggravation of Ebola risk is not performative, but rather just silly, as when it says, “The traditional custom of returning, often over long distances, to a native village to die and be buried near ancestors is another dimension of population movement that carries an especially high transmission risk.”

Considering how normal going home when you get sick, or have a terminal illness, is in Europe and the United States, I do not imagine it would have terribly harmed the WHO to have not referred to the practice as a “traditional custom” peculiar to West Africa.

This post on the challenges of carrying out a census in rural towns served by bad roads will be familiar to anyone who’s done quantitative data collection in a low-income place.  However, there’s also a novel point here about how “there are fewer lower limits on the size of settlements” in places without schools or clinics, as it suggests that the type of practices used to manage population density in the precolonial era are still in use today.

I’ve spent much of the last two weeks poring over government and NGO tables and maps of settlements in southern Liberia, and having discussions about the same.  …  Part of the issue is that much of rural Liberia is fantastically difficult to survey, with the result that well-meaning statisticians and demographers do their counting in places that are easy to count, and presume that places that are hard to count are rather like them. In other cases, tables include data only from parts of the country where the ministry doing the counting has an office, or has an employee. …  [In addition,] when it is the case that schools, roads, clinics, and so forth are not available for long periods of time (or that their presence is actually a risk factor for violence, as it might be in a civil war), there are fewer lower limits on the size of settlements, and thus great profusion of places that may or may not be counted in a particular tally.

Employee absence as an indicator of patronage

I attended an interesting presentation recently by Michael Callen (UCSD) on the political economy of public employee absence in Pakistan (PDF).  In an observational study of doctors at public clinics in Pakistan’s Punjab region, he and his co-authors found that doctors who personally knew their MPs were almost twice as likely to be absent as those who did not.  Furthermore, doctors in districts which were less politically competitive, and where their sponsoring MPs would thus face less risk of public backlash over poor service provision, were more more likely to be absent than those in competitive districts.  The idea here is that MPs face two conflicting incentives: it’s cheaper to them to provide patronage goods (like jobs in the public health service) to individuals in exchange for votes, but if they face political competition, they instead have an incentive to try to provide higher quality goods to more voters.

Links of the day

  1. Stability, the International Journal of Security and Development, is a new open-access journal which aims to quickly get relevant academic research to policymakers.
  2. Tom Murphy points out that cancer kills many more people in low income countries each year than does HIV, and Think Africa Press writes that the severe lack of opiates in Africa makes palliative care for cancer victims quite difficult.
  3. Must African presidential aspirants go to prison before they take higher office? (In French)
  4. Videos of cash transfer recipients in Kenya and Mozambique telling their stories in their own words.
  5. A new RCT questions the external validity of RCT-proven results (a political economy story about implementing organizations), and a study from Brazil finds that rainfall fluctuations during pregnancy are associated with changes in infant health outcomes, calling the use of rainfall as an instrument for just about everything into question.

Travel Advice for Low Income Countries: Health

Last but not least in the travel advice series: staying healthy.

Don’t bring:

  • An obsessive fear of illness.  Disease-related morbidity is certainly higher in low income countries than in high income, but if you have the money to travel then you have the money to stay healthy.  It’s an object lesson in public health.

Do bring:

  • Sunblock (which you should be wearing every day anyway!).  I like Lubriderm’s SPF 15 moisturizer, which is unscented and non-greasy.  If you’ll be outside for long periods, get waterproof sunblock in a higher SPF and reapply frequently to make sure you don’t sweat through it.
  • Hand sanitizer.
  • DEET-free bug spray.  DEET is effective, but it’s inconvenient to wash it off before bed every night, and isn’t recommended for use with small children.  I’ve been happy with Repel’s lemon eucalyptus insect spray.
  • Anti-malarial medication.  Malarone and doxycycline are commonly available in the US.  Mefloquine is no longer available by its brand name, Lariam, but is still sold as a generic.  All of them have a non-negligible prevalence of side effects (with mefloquine being known for being hallucinogenic, doxy for causing sun sensitivity, and Malarone for milder effects), so discuss the choice with your doctor.  It is sometimes possible to purchase brand-name anti-malarials like Malarone in low inome countries, but it’s not always available and is sometimes counterfeit, so it’s preferable to get them before departure.
  • Extra dosages of prescription medications, and copies of prescriptions.
  • Anti-nausea and anti-diarrhea medication.  If your body truly wants to get rid of something it’s eaten, I usually think it’s wiser to let it do so, but if this conflicts with a 14-hour bus ride then Pepto-Bismol will be helpful.  (If you’re worried about dehydration, it’s simple enough to make your own ORS from sugar & salt.)
  • An extra pair of glasses, if you wear them.  Keep your last pair as back-up when you get a new prescription.
  • Iodine tablets for water purification.  Useful if you can’t buy clean water or boil before drinking.  Potable Aqua makes a taste neutralizer that completely removes the iodine flavor.

Do get:

  • The rabies vaccine.  Rabies isn’t a huge problem in most places, but it does exist almost everywhere, and is nearly 100% fatal if you contract it and are unable to get treatment.  Getting the prophylactic vaccine before departure will buy you several extra days to get help if you’re bitten by an animal.
  • Deworming pills at a local pharmacy.  Only important if you’ve been exposed to water or food in places where open defecation is common.  Most local pharmacies will have them.

Eight books on development for the interested generalist

A friend recently asked me for a list of interesting books on development, and I thought I’d share the results here.  I read almost randomly in the field when I was still trying to narrow my initial broad interest in development down into something of which a career could be made, and the books below generally struck me as the most interesting, accessible, and generally well-supported introductions to their respective subject areas that I came across.  (I haven’t read some of these in years, but in retrospect I think they’d all stand up decently to a reader with greater existing knowledge of development.)  In roughly descending order of intellectual impact upon me:

  1. Development as Freedom, by Amartya Sen, is one of the best books I’ve read on the general concept of “development.”  It addresses a number of common critiques, and creates a strong philosophical framework to support the argument that “development” is still necessary.
  2. Portfolios of the Poor is my favorite book of 2009 – an incredibly thoroughly-researched look into what poor people do with their money and how microfinance plays into this.  I don’t remember learning more from a single book, well, probably ever.
  3. Understanding Poverty is a great introduction to a huge range of issues in development, from food security to education to microfinance.  It’s written by a group of leading development economists, often from a behavioral perspective, and the thought contained here is both wide-ranging and rigorous.
  4. This is a bit quirky compared to the other recommendations, but I very much liked Expectations of Modernity, an ethnography of Zambian copper miners in the ’70s and ’80s.  The description probably sounds boring, but it’s actually a great critique of the idea that people from low income countries who act in “Western” styles are blindly mimicking the West, instead of consciously bringing elements of Western culture into their lives in ways that reflect their own social & economic interests.  It basically lays out a strong case for relativistic understandings of culture, which I find hugely important for any development worker, without framing it with that potentially off-putting phrase.
  5. The Bottom Billion has held up better in retrospect than its two better-known contemporaries, The End of Poverty and The White Man’s Burden, at least in my recollection.  In a foreshadowing of my current interests, I liked its focus on research methodology in macroeconomics (i.e. where all that data underlying cross-country regressions comes from), and its quantitative look at the connections between war, governance and poverty.  (Edit: David Roodman points out his own and Easterly‘s critiques of Collier for data mining in Wars, Guns and Votes, and believes that they’re applicable to The Bottom Billion as well.  I’d suggest enjoying the intellectual curiosity of Collier’s research, but taking his statistical results with a grain of salt.)
  6. I can’t offer too much on the subject of public health, but I did greatly enjoy The Wisdom of Whores, which is an engaging book about health systems responses to HIV from the ’80s onwards, told by an irreverent epidemiologist with whom I would very much like to have a drink one day.  It’s also a great critical look at where public health data comes from, how it’s used, and to some degree why governments and international organizations choose the health priorities that they do.
  7. Making Globalization Work is something I recalled as insightful on the topics of global financial institutions, markets and trade at the time I read it.
  8. I’ve been trying to find a good overview of the World Bank that I read for a geography class a few years ago, and while I’m not sure that I’ve identified it, The World Bank: From Reconstruction to Development to Equity looks like it covers similar subject matter. I found tracing the Bank’s historical evolution quite interesting, as it also captures the variety of Western thought on “development” that’s occurred over the past 50 years, and explains quite a lot as well about current bilateral and multilateral aid regimes.

Tell me, dear readers, what else would you recommend for the interested lay reader?

Intra-household resource allocation

I’ve been reading a great deal recently about the linkages between food availability, intra-household resource allocation, and nutritional status, and it’s made me wonder about time-specific determinants of resource allocation.  That is, it’s clear that there are some systematic, long-term differences in allocation connected to overall education levels, overall income, and gender.  What I’m curious about are short-term, potentially more idiosyncratic effects: for instance, are women more or less likely to command adequate nutrition if they fall ill?  Are there differences between the amount of food received at home by, say, a young child in school (potentially also benefiting from a school lunch program) and an older child who drops out to care for younger ones or help in the fields? How much would one discount future education (for the young child) versus immediate ability to do work in that case, and how might one be able to change that calculus if it weren’t a long-term beneficial one?

The obvious connection to pro-poor financial services lies in the oft-noted social “shock” of women suddenly receiving access to credit when they previously had none, which disrupts existing allocation schemes and may result in tension or violence between women and their relatively disempowered husbands.  I can think of a few specific predictors of violence or generally negative reactions in this case – a history of prior violence being the most obvious one, or a husband’s unemployment, or a cultural injunction against women handling money – but I wonder if there are other traits that could be used to predict whether men might react poorly to women’s credit, and perhaps develop plans to defuse this scenario.  I’ll have to think some more about this.  The intersection between culture and credit is a fraught and fascinating one.