mHealth free-for-all in Uganda

The Uganda Ministry of Health recently put into effect a moratorium on eHealth/mHealth projects in the country. Perhaps this is why:

Pilotitis in Uganda: mHealth mapping

Map of mHealth pilots in Uganda by Sean Blaschke (Unicef Uganda)

When to intervene?

Published online April 24, 2012.

In our interconnected global community how does identity influence one’s actions?

“First they came for the Socialists, and I did not speak out– Because I was not a Socialist.
Then they came for the Trade Unionists, and I did not speak out– Because I was not a Trade Unionist.
Then they came for the Jews, and I did not speak out– Because I was not a Jew.
Then they came for me– and there was no one left to speak for me.”

This famous quotation comes from public lectures given by protestant pastor Martin Niemöller, a critic of Adolf Hitler who was imprisoned in Nazi concentration camps for seven years. Like many others, he expressed lifelong regret at having failed to act sooner as the Nazis murdered millions. His faith differed from most of those who were persecuted, but the painful lesson he learned was that one’s identity should not dictate one’s actions, or the lack thereof. Unfortunately, this lesson remains relevant today.

Still, questions remain. When do you have a responsibility to help someone? When are other people’s problems also your problems? In the face of obvious wrongdoing or a natural disaster, is it always better to do something than nothing? The answers to these questions are not obvious, even if Niemöller’s words ring true. Injustices, atrocities and accidents occur daily, but as an increasingly interconnected global community, we have not figured out when and how we are supposed to act, either as individuals, organizations, or governments. Many argue that national boundaries should dictate who and what we are responsible for, but upon closer examination, this argument falls apart.

Nationality is one of the most common social categories we use to define our identity, and for good reason. Our nationality, our citizenship, plays a large role in determining where and how we live. We look toward nation-states to dictate the behavior of individuals and governments, and physical boundaries are also those used to assign rights, privileges and obligations. Furthermore, nationalism is not just a facet of our identity, but is deeply embedded in the international system. The norms and rules of sovereignty have for long prevented one country from wandering willy-nilly into the affairs of another (which is not to say that this happens infrequently).

For this reason, human rights advocates, non-governmental organizations, and international organizations like the International Criminal Court, often viewed as proxies for “western” governments, not to mention governments themselves, are often lambasted for meddling in the affairs of countries like the Democratic Republic of Congo, Rwanda, and Uganda. Governments of countries on the receiving end of intervention complain loudly about the imposition on their sovereignty. Citizens too are repulsed by the idea and actions of foreigners who behave as if they know and understand a place or problem better than the people who live there.

But it is not clear why national boundaries alone should dictate our rights and responsibilities. Physical boundaries are becoming increasingly porous, and arguably, irrelevant. What happens halfway around the world is not only visible, but also something in which individuals far and wide can have a stake. Following the tsunami in Indonesia or the earthquake in Haiti, individuals raised hundreds of millions of dollars, channeled not through governments but rather through non-governmental and international organizations.

It is clear that individuals can make a difference, but the question is when should they? It would be silly to suggest that we should only care about things that happen in countries where we hold citizenship. Why? At least in part because the selection of nationalism as the key factor for determining whether or not to act is arbitrary. If we should only care about “people like us” or stay out of “other people’s” affairs, an argument that begins with one’s citizenship as the relevant identity may quickly reduce down to a sub-national identity, or worse, race, religion, ethnicity, gender, or class.

It is surely not the case that we should only care about or attempt to redress injustices if the offended party shares our race, ethnicity, hometown or income level. An argument that lists nationality as the key determinant of whether or not we have a right or responsibility to act is no different and no better than one listing any of our other identities as the deciding factor. Each one of us has many different, and largely socially constructed, identities. For example, I am an American, born in the state of California, in a town called Palo Alto, to a Mexican father and an American mother. I was baptized and confirmed in a Lutheran church. I have light skin. I am a woman. Should any of these categories, any of these identities, limit who or what I care about? Under what conditions should any of these identities dictate how I act?

If identity (of any variety) should not be the determinant that dictates our rights and responsibilities to act, what should be? We do not have an answer to this question. What we do have is the creation of social categories around which it is easy to mobilize but also easy to persecute, the creation of “us” and “them”, “foreigners” and “locals”. Such a framing is neither productive nor sustainable.

Perhaps information, knowledge, or understanding should be a prerequisite for action. Much of the critique about “meddling” in other people’s affairs stems from the fact that the meddling is often poorly informed. The road to hell is paved with good intentions, as the adage goes. First do no harm, says another popular mantra. Unfortunately, the simplicity of these axioms is misleading. We often do not know whether our actions will, on balance, be more helpful or harmful – it is often impossible to measure one’s impact, even years after the fact.

Yet if we fail to act, we are in danger of becoming bystanders to massive atrocities. Many who looked on as the Rwandan genocide unfolded became exactly that – bystanders whose crimes were those of omission. So too were those who looked away as the Nazis summarily wiped out over six million people. More recently, we have faced crises in Libya, Bahrain, Syria, and beyond, as regimes have clobbered and battered their populations into submission. Rebel groups like the LRA continue to terrorize with abandon. The fundamental questions remain. Should we act? When? How?

The crumbling myth of invincibility

Published online April 16, 2012.

The recent fall of three leaders exposes the myth of invincibility

In the past few weeks we have witnessed three modes of succession in Africa:  a coup, an election, and a death in office. Former Malian president Amadou Toumani Toure fell in a coup led by army officers on Mar. 22. A few days later, Senegalese president Abdoulaye Wade lost in a run-off election to a much younger and wildly popular opposition candidate, Macky Sall. Only weeks later, Malawian president Bingu wa Mutharika suffered a sudden and fatal heart attack, paving the way for vice president Joyce Banda to take the reigns. Now Mali’s coup leaders are themselves facing yet another transition as an interim president is ushered in.

The results in Mali and Senegal are being celebrated, one could say, as the christening, or perhaps the confirmation, of democracy. An election carried the day in Senegal and an unconstitutional takeover of government in Mali is being rolled back. Malawi could pass too. Joyce Banda is the new president, thwarting a feudal-like succession of wa Mutharika by his brother. Still, Malawi remains a work in progress.

For most people, presidents and prime ministers are conjured up imaginings both grand and grotesque. We talk about some as tyrants or despots. Others we call “father of the nation” or perhaps, philosopher-king. While we know that these individuals are human, their reputations – whether good or bad – often make it difficult to think of them as such.

I don’t often spend time with heads of state, but two years ago I attended the 2010 African Union Summit in Kampala, where dozens of leaders had come to gather. At that conference were many of the almost mythical characters we spend our days talking and writing about. Among them, Muammar Gaddafi, Abdoulaye Wade, Mwai Kibaki, Goodluck Jonathan, and Bingu wa Mutharika, the latter of whom chaired the session. These men (and yes, they were nearly all men) suddenly became real to me in a way they had never been before. They were no longer an abstract idea but flesh and blood, sitting around a satin green and white clothed table in a tent pitched on the banks of Lake Victoria. They sipped water and waited for translations in their headphones. At that moment, they did not seem powerful so much as vulnerable.

Sometime last year I woke up to the awful footage of a bleeding Gaddafi, dragged and beaten through the streets near his hometown of Sirte, Libya. My first thought, after my horror, was of the sunny days of the summit when for a brief moment Gaddafi was not an abstract “tyrant” but a terribly mortal human being, even if an extravagant one. Then a few days ago, the news of wa Mutharika’s passing again brought me back to memories of the summit, watching and listening to the Malawian president’s numerous speeches. This is not, of course, to say that there were many similarities between the two former leaders, apart from one thing – they were both men, in the mortal sense of the word.

I rarely have such opportunities to see the human side of world leaders, but it strikes me that leaders themselves inevitably do. Watching the fall of Toure, Wade, and wa Mutharika must be terrifying for many current office holders. Here they have not one but three distinct (and yes, plausible!) means of losing power. The greatest asset for many long-time leaders is precisely their non-human qualities. It is the creation and sustenance of a myth of invincibility, the suspension of reality. You can be sure this myth is in place when you cannot imagine a future without the Dear Leader, when a person and nation get fused together. Gaddafi and Libya is a perfect example of this. So too is Mobutu and Zaire, Mugabe and Zimbabwe, Kim Jong-Il and North Korea, the Saudi royalty and their kingdom. Often these men live so long that you even begin to believe that something supernatural must be at work. Alas, all things good and bad must come to an end.

Leaders, however powerful and long-lived, are increasingly bombarded with reminders of their own mortality, political or otherwise. So too are their publics. The myth of invincibility is deteriorating quickly, and its destruction accelerates with every political transition. As a leader, what lessons can be learned from these recent turnovers?

For one thing, the increasing strength of political institutions cannot be overlooked or underestimated. The days of overrunning constitutional power are not over, as the case of Mali demonstrates, but their days are numbered. The triumph of constitutionalism in Senegal, Malawi and even Mali provides evidence that the supremacy of the law is very often real. Articles of the constitution may seem innocuous and pliable, but they provide a focal point for society. The law, written clearly for all to see, provides a line in the sand between just and unjust. Those who dare to cross that line do so at their own peril.

Moreover, the legacies of leaders are increasingly dependent on their respect for and adherence to these maturing political institutions. Leave the political playing field graciously and you will be heralded as a champion of democracy and progress. Stick around to play by the old rules, and you will likely find yourself kicking and screaming all the way to The Hague.

Finally, if leaders worry over their own mortality, they had best get their national hospitals in tip top shape. This business of flying to South Africa (much less Singapore) for medical treatment, a luxury reserved only for the elite, is absurd. South Africa is too far when a health crisis strikes, even if you have your own personal jet. If it takes selfish fear on the part of leaders to prompt the development of good medical facilities, so be it. No one said development has to be an entirely selfless enterprise. Just get on with it already.

Our biggest development challenge

Published online April 11, 2012

Why solving inequality is a must for Africa’s development

In the morning young children brush their teeth outside makeshift houses as a snaking line of Range Rovers crawls by.  In the afternoon, businessmen fill cafes while street vendors peddle their goods in a sea of commuters inching towards home. In the evening, toddlers sit transfixed by flat-screen TVs while their neighbors sit playing by candlelight. We are living in a world where shopping malls are popping up alongside young boys herding cattle – a clash of peoples occupying the same space but living lives that bear no resemblance to one another.

Rarely in history have such extremes coexisted. The yawning chasm between rich and poor is palpable but not physical – lives but not livelihoods overlap. In some ways, disparities in wealth are inevitable. Countries whose average annual income is in the hundreds of dollars but whose annual economic growth soars at rates of 5% and beyond are bound to experience uneven transitions to prosperity. Access to opportunities, education, even liquidity is not even or equitable. We can’t wish away these disparities, but sooner or later, we will have to address them.

This was also the message of a keynote address by John Githongo, Kenya’s famous whistleblower, at a conference on innovations in governance a month ago at Stanford. I had heard a lot about Mr. Githongo and read Michela Wrong’s popular book, It’s Our Turn to Eat, which documented his time fighting corruption in the administration of Kenyan President Mwai Kibaki. Nevertheless, I wasn’t sure what to expect from him. I had heard so few critical words about the man that I began to become suspicious – surely he could not be as saintly as depicted! Like all of us, Mr. Githongo surely has his flaws, but I have none to report. His speech was simply exceptional.

The message? Inequality is the primary development challenge of the next few decades – inequality of outcomes and opportunities, of expectations and aspirations. Inequality is not only morally repugnant but also easy to politicize, ethnicize, and militarize in Africa, he argued.

Herein lies the real threat to development  — a new round of conflict and instability triggered by inequalities that are the product of the very economic transitions for which we strive.

Githongo likened our current state of affairs to a meeting of old and new technology. We have often been successful in getting right the hardware of the state – infrastructure, education, health – or at least making noticeable progress in these areas. However, the software, made up of political rights and freedoms, is outdated. Combining old software with new hardware is like buying a brand-new Dell laptop and loading it with Windows ’95 – it will have a blue-screen! And what follows is not pretty.

Where political opposition and mass protests have been successful at toppling regimes, there has frequently been a political hangover. After the euphoric triumph of the many over the few comes the realization that updating the software of political freedoms and institutions does not happen overnight. The end of dictatorship does not call for champagne. The inequalities that prompt regime collapse do not disappear with the despot.

The challenge of political instability provoked by inequality is particularly acute in urban areas. There are vast disparities between rural and urban populations, but it is the inequality within urban areas that seems to drive most conflict. Revolutions rarely begin in the countryside.

The hopefulness of the Arab Spring just one year ago has given way to the realization that we do not know how to cope with the mobilization of society based on inequalities, whether economic or political. Sitting governments often retaliate violently, exacerbating societal tensions that are already on the verge of a breaking point. Ordinary citizens do not know whether to join the masses in protest, run for their lives, or sit tight and wait for calm. The dominant actors on the world stage shout past each other, often rendering impotent international institutions like the United Nations.

The good news that in many places, the software is being updated, albeit in fits and starts. Coups and election violence notwithstanding, there have been gains in political freedoms across the continent. The development of the media, slow strengthening of parliaments, widespread acceptance of elections, and multitude of multiparty elections that have increasingly resulted in regime transitions are all evidence that political freedoms are far from stagnant.

Of course, just as with a computer, it is frustrating when the machinery of politics and society temporarily freezes or crashes. You lose your work, and you lose time. But if we are discouraged at the pace of progress, we have not only to look at ruling parties but also at the would-be political and social entrepreneurs who have not always put pressure on the powers that be or provided a viable political alternative. Inequality has allowed political opposition to mobilize the masses, but what comes next? Without organizational or institutional infrastructure, opposition parties and coalitions are unlikely to prove any better than the regimes they oppose.

Watching cities like Kigali or Kampala increase in size and wealth is inspiring, but the gap between the “haves” and “have nots” is also larger than ever before. Inequality will not vanish as countries grow, and may eventually impede or even threaten further progress. For this reason Githongo’s case is a strong one: inequality will be one of the greatest development challenges of this generation. I think we have the tools to avoid a meltdown. Everyone knows what Windows ’95 is a dinosaur. The question is, who is in charge of the update?

Bad news sells, are you buying it?

Published online April 3, 2012

In the past several weeks there has been much discussion of Africa’s image, prompted in large part by the Kony 2012 video (which has become too exhausting to discuss at this moment).

There are perpetual debates about Africa’s leadership, political or otherwise, and the prospects for continent’s future. These conversations are played out everywhere from the airwaves to your neighborhood bar.

The arguments are not new. Africa gets a bad name and her image is tarnished by unrelenting negative press.  Western media, it is argued, is particularly problematic, projecting an image of Africa that paints Africans as both hapless and helpless and the western world as their saviors. The stories that sell are those that deal in death and violence, poverty and hopelessness.

At the same time, the debates on local radio stations and in the streets are often just as pessimistic. Headlines in local papers highlight corruption scandals, the failure of public services and violent deaths.

Why is it so much easier to sell and tell a negative story? The western media alone are not the culprits; bad news sells everywhere. And the pubic is complicit, after all, as consumers of bad news. Critical views, especially those aired publicly, are important for accountability and multi-sided public debate is valuable in its own right. But at some point we have to interrogate our own role in shaping the debates about society, politics, and progress.

I recently returned to Kampala after a 6-month sojourn in the U.S. and as always, I am always amazed by the changes that have taken place while I was away. Granted, I am occasionally greeted by the expansion of a pothole I thought had finally been filled up for good, but more often than not, the changes are positive ones.

Every time I come back there are new buildings that have gone up, new shops that have opened, and new businesses and products breaking into the market. The streets of Kampala are cleaner and less cluttered than when I left them. Fewer matatus crowd the roads and public buses bustle efficiently through town. City garbage collectors dash to their trucks with bags full of trash and scoop up plastic bottles that have clogged drains and ditches. The same is also true, though less surprising, whenever I visit Rwanda.

This time around, I arrived in the midst of a roaring debate about who was responsible for the death of a policeman who had been hit in the head with a stone during a demonstration by the opposition group, A4C. Following this incident, Ugandan president Yoweri Museveni visited the home of the fallen officer, and photos of him with the grieving family were splashed all over the papers. The policeman’s clearly meager existence prompted debates about the poor pay and living conditions of the police, and many saw President Museveni’s house-call as a political maneuver.

I struck up a conversation with a cab driver one evening not long after the demonstration. The young man fully blamed the policemen for the unfortunate event, and remained an ardent supporter of de facto leader of the opposition, and the leader of that particular demonstration, Kizza Besigye. The young man had lived under the same president his entire life, and was tired of Museveni. University graduates can’t get jobs, he said, and everything is run by members of the same ethnic group – the president’s ethnic group. There is no change, he said.

We drove past one of many multi-storied buildings under construction. What about all this construction, I said, pointing – this city is growing and changing every day. He laughed. That building is owned by one of five people, like all the buildings in town. Both of his mobile phones began ringing and we drove on.

There is much to be frustrated about when it comes to governance and political leadership, whether you are in East Africa or elsewhere. Change does not come soon enough, and when it does, it comes in fits and starts. Politicians everywhere tend to flip flop on important issues, and then pick petty fights to derail what would otherwise be good policies. Corruption and unemployment are high, and access to economic and political opportunity is not equal. But the narrative, whether at home or abroad, is often hyperbolic. The positions that get the most attention are those that are most extreme, and thus there is an incentive to make them so.

Bad news sells, and we are just as responsible for this state of affairs as the news organizations we are so quick to castigate. We are addicted to narratives that we hate, and we gravitate toward clichés that we know can’t be true. The same phrases sprinkle news stories time and again, and while we sneer at them, they play a tune we can easily sing along to.

The stories aren’t going away anytime soon, and even good news plays to stereotypes. Senegal’s recent presidential turnover had commentators falling over themselves – they always knew the country had been a “beacon of democratic stability in a troubled West Africa!” Rather than passive consumers of these hackneyed formulas, we fight back, as we should. But no sooner do we switch off the radio than we become producers of our own hyperbolic platitudes.

As we approached home my driving directions periodically interrupted our lively cab-ride conversation – turn right at the dirt road, turn left after that house. There are still no street signs and in the final stretch we bumped along on dusty roads. But alongside them are a string of new homes and a towering apartment complex. A sprawling new shopping mall has sprung up just moments away from home. No need to join the Saturday rush into town to shop these days, which is great news. There are simply too many cars on the road!

Faith in Politics

I’ve been traveling and have fallen a bit behind in posting my columns. Below is my article published a couple of weeks ago, and published online March 27, 2012. I’m starting to think a lot about the intersection of religion and politics, so there should be more on this topic soon.

Faith in Politics
The strategic and influential role of religion within our political systems

There is a certain structure religion gives to our lives. At the birth of a child or death of a loved one, we turn to some sort of faith more often than not. When oaths are sworn in courts of law, it is a holy book on which we swear to remain truthful. And when politicians promise to abide by the earthly laws we create, they raise a hand and address a god somewhere.

Faith shapes our lives, but not our governments – at least not directly, and not on paper. Laws uphold and protect only the legal separation of church and state in most countries. This formality can trick us into thinking that religion keeps its distance from politics. But the truth is that the two have never really been separated.

Simply take a look.

There are prayer breakfasts, the invocation of god’s name in such places as national anthems and currencies, and prayers at the start of government meetings and functions. Heaven forbid a U.S. president should end a national address without the words, “God bless America”. Although these are benign examples of the blending of church and state, the clashes can be much more fierce when religion comes head to head with public policy.

In the United States, there are vicious, and even deadly, battles over abortion laws and the teaching of evolution, as opposed to the more biblical creationism, in schools. In France, veils that cover the face (such as the hijab or burka) are banned in public places. In a number of African countries, including Uganda, marriage laws have been unsuccessful at prohibiting polygamy because such a ban is seen to violate religious practices.

These are perhaps some of the most blatant and controversial clashes between faith and the state, but the religious beliefs of political leaders can also sneak into their public policy in less obvious ways. The support of evangelical Christian groups for HIV/AIDS advocacy played a significant role, for example, in shaping and promoting U.S. President George W. Bush’s global HIV/AIDS initiative, The President’s Emergency Plan for AIDS Relief (PEPFAR). Even groups like Invisible Children, responsible for the viral Kony2012 video, are not outwardly evangelical, but are nonetheless headed by individuals whose religion plays a prominent role in the way they view their purpose in the world.

While it is tempting, especially for dispassionate analysts and policymakers, to take the separation of church and state at face value, it is necessary to more closely interrogate the ways in which faith shapes not only individual actions, but political systems. How does religion affect our political, social, and even philanthropic lives?

In an environment where voters have precious little information about their elected officials, apparent adherence to religious beliefs and practices can give some indication of the quality of a candidate. In an era of rampant corruption, a candidate who is perceived as religious may be more trustworthy than his or her atheist or less devout counterpart. U.S. presidential candidates, for example, must repeatedly discuss and proclaim their faith. Stories of redemption and renewal, often brought about by religious transformation, also win votes. A story of salvation from alcoholism and other exploits painted an inspiring image of former President Bush that many Americans admired, and one where faith featured front and center.

Indeed, many voters use faith as a prerequisite for their support of a political candidate. 35% of Americans and 45% of Rwandans surveyed by the World Values Survey believe that “politicians who don’t believe in God are unfit for office.”  Moreover, 62% of Rwandans and 42% of Americans agreed that it would be better if more people with strong religious beliefs held public office. As a politician in either of these countries, it only makes sense to announce your faith publicly.

At the same time, going into too much detail about your faith can be almost as career-killing as not mentioning it at all. It is one thing to be Christian, but quite another to be Mormon, much less Muslim. Most Americans and Rwandans are Christian, either Protestant or Catholic. About half of all Americans are Protestant, while a quarter are Roman Catholics, and less than 1% are Muslim. In Rwanda, the numbers are flipped – nearly 60% of Rwandans are Roman Catholic and 26% are Protestant. Another 11% are Adventist, and 5% are Muslim.

Politicians who do not come from the predominant Christian denominations are hard-pressed to demonstrate that their beliefs are not far removed from “mainstream”. U.S. Republican candidate Mitt Romney, for example, has been at pains to assure voters that as a Mormon, his beliefs to not differ greatly from those of more mainstream Christianity. But if Romney thinks he has a hard time, his experience would surely pale in comparison to a Muslim candidate. I would wager the U.S. is about as far from electing a Muslim president as any country on earth.

Perhaps it is not surprising that faith plays an important role in shaping people’s political preferences, even in a secular state. Nevertheless, the process by which faith seeps and soaks into politics and policy is not straightforward. Anecdotal evidence suggests that churches and religious leaders are a powerful force driving the political behavior of their followers. After all, from their pulpits, religious leaders have a great and even unique opportunity to shape public opinion. At the same time, however, most people do not react favorably to the explicit interference of the church in political behavior. About 60% of both Americans and Rwandans believe that religious leaders should not influence how people vote, and nearly 70% of Rwandans do not think religious leaders should influence government.

Thus, there is an ideological tug-of-war underway. On the one hand, citizens living in secular countries subscribe to values of religious tolerance and even the religious agnosticism of the state. On the other hand, they often favor politicians who declare their faith, and punish those whose faith is not in the mainstream. To understand how faith intersects with politics, these two conflicting preferences must be reconciled. The question remains, to what extent do we have faith in politics?