Malawi: First Thoughts

To understand any place, you have to leave it. It’s only with a comparative perspective that you recognize the significance of things you take for granted on the one hand, or the things you lament daily on the other. That’s how I’ve felt, anyway, during this past year of working on my dissertation, based in Uganda and working briefly in Ghana, Nigeria, Kenya, Burkina Faso, and now, Malawi.

I flew into Kamuzu International Airport in Lilongwe yesterday afternoon. From Kampala it’s a short trip, feeling much like the journey from San Francisco to Chicago, and making intra-continental travel seem easier than it normally does.

There are no immigration forms to fill upon arrival in Lilongwe (at least the day I arrived), but they do check for your Yellow Fever card. How did Yellow Fever, a relatively uncommon disease, become the single most common (only?) vaccination required worldwide? I was thankful I had remembered my aptly colored yellow Yellow Fever card, but others who didn’t have one seemed to get through just fine. While the card is ostensibly a requirement in lots of countries, apart from Malawi I can only ever remember being checked in Nigeria.

At the immigration counter, I was not asked what I would be doing in Malawi, or how long I would be staying. There were no forms to fill out, no visa fees to pay. My fingers were scanned, photo taken, and off I went. I bought a SIM card at the airport, no registration required, and got cash from the ATM. The road from Kamuzu to Lilongwe was practically deserted; a few homes dotted the otherwise empty roadside. The road was smooth, the air hot, the ground dry. I wasn’t sure we had arrived in Lilongwe proper until I started to recognize the names of lodges I had seen in guidebooks. By contrast, coming from Entebbe you may think you’ve reached Kampala, only to find yourself snaking slowly through the city limits an hour later.

The quiet and winding streets of the Lilongwe, lined with trees, remind me of Kigali, as does the relative absence of people. While Kampala, Lagos, Nairobi, and Accra are churning, bustling, and often overwhelming, Lilongwe has a distinctly understated presence.

Uganda’s economy is nearly five times the size of Malawi, Kenya and Ghana about twice that of Uganda, and Nigeria far bigger than all four combined. The largest bill you can get in Malawi $2.50, Uganda, $20, Kenya $11, Nigeria $6, Ghana $23. As you can see, there is no relationship between bill and economy size (or GDP per capita, for that matter), which makes spending and taking out money much easier in Uganda and Ghana than in Malawi or Nigeria. In both Nigeria and Malawi (yes, with my limited experience of one day in the latter),  ATMs appear to be frequently running out of money, and sometimes with very long queues. I’m no economist, but something about tiny bills seems very inefficient. Is there an upside? Any work on the politics of moneymaking, literally?

Finally, although I generally dislike the tradition (requirement?) of adorning the walls of every establishment with presidents’ photos, it is a welcome change to see — for once if not for long — a woman in the frame.

That’s all for today. More comparative musings soon.

Update: Relatedly, though I don’t fully agree: “Africa? Why there’s no such place” h/t to my partner in crime.

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?

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?

The King and Queen-makers

Published online February 28, 2011

Driving through the countryside or city streets in Uganda or Rwanda, one is greeted by the same sight over and again – children. Youngsters in colourful uniforms fill the sidewalks and paths every morning and afternoon as they trek to and from school.

Jogging in the early morning down Kigali streets I have more than once been embarrassingly out-run by little girls in dress shoes and backpacks, screeching gleefully as they dash past. Meanwhile, the smaller children toddle curiously around the home, and babies find themselves securely strapped to the backs of their busy moms. You don’t have to look up demographic figures to know that one word characterizes the population: young.

In a region long defined by civil war, violence and dictatorship, youth is the new and hopeful quality permeating society. The wars that wracked the region for the past several decades have drawn to a close, one by one – the Ugandan civil wars of the 1970s and 1980s, the 20-year terror of the Lord’s Resistance Army in Northern Uganda, the Rwanda genocide of 1994, and the Congo wars that followed. As the worst episodes of violence recede, how will newfound security affect the political, social, and economic opportunities and beliefs of the new generation? How will the youth relate to the decisions of leaders whose lived experiences are increasingly distant from their own?

The children and young adults of today will live profoundly different lives than those of their parents and grandparents. While conflict continues in eastern Congo, a peace and cautious hope has come to most of the region. Nearly half of Rwanda’s population today was born after 1994. 52% of Rwandans and 61% of Ugandans are less than 20 years old. Nearly three quarters of all Ugandans have lived under President Yoweri Museveni for their entire lives.

Most Ugandans and Rwandans, therefore, know only stories of the terrible wars that once ravaged society. The scars, visible or not, are everywhere, but the memory is increasingly derived from history passed down by those who lived through it. As these children come of age, they face very different challenges than their parents before them. The vast majority will attended primary school, and will read and write in English. Many will graduate from secondary school, and an increasing number will obtain a university degree. Unlike their parents, most will not fear for their lives, but for their livelihoods.

Yet for now, those who govern the countries in which these children grow up – individuals who were intimately involved in the conflicts of the past several decades – continue to make calculations, judgments, and risk assessments based on the experiences through which they have survived, as have done leaders before them. National security is at the top of the agenda for every government, but the price one is willing to pay for security is shaped by experience. For the older generation, there may be no price too high. For the younger generation, the choices may not be so clear-cut.

It is difficult to assess the extent of the divide between today’s youngsters and the generation that preceded them. Often votes are a good indication of political and policy preferences, but the post-conflict generation is only just coming of age. Surveys too can help, but ultimately we are left to some speculation.

Recent surveys in Rwanda show that both the young and old continue to place a high value on national security. Overall, 44% of Rwandans said that “strong defence forces” should be the top national priority, with a similar percentage across all age groups, according to the World Values Survey. In the U.S., by contrast, while 38% of all Americans surveyed believe strong defence forces is the most important national priority, only 20% of those under 30 list national defence as the top priority. The vastly different security challenges facing each country have surely shaped these preferences.

In Rwanda, an extraordinarily large percentage of people not only support strong defence forces as the top national priority but would also contribute to this goal – 95% of all Rwandans and 96% of 15-29 year-olds surveyed said they would be willing to fight for their country. In the U.S., only 41% of 15-29 year-olds were willing to do so. 91% of Rwandans also expressed a preference for greater respect for authority in the country. All this suggests that so far, there is little evidence of a generational difference in security preferences. Nevertheless, it is important to keep in mind that most of the peacetime generation is still too young to be included in any survey. We are likely still observing the preferences of an adult population for whom the remnants of conflict may still be too fresh, and continued violence in eastern Congo too close.

In Uganda, evidence is mixed regarding whether the old and young have different preferences when it comes to national priorities, but there appear to be greater differences than in Rwanda. There are obviously serious economic challenges facing Ugandans, which may trump security concerns for the ordinary citizen — 64% of 18-29 year-olds were unemployed in 2008, according to an Afrobarometer survey. For most Ugandans, “improving economic conditions for the poor” is the most important national priority. Only 17% of 18-29 year olds listed maintaining order in the nation as the highest priority. Interestingly, young people expressed greater fear of political intimidation or violence than the very old in Uganda – 36% of young people said they had “a lot” of fear of political violence. And worryingly, the majority of Ugandans believe political competition often or always leads to conflict.

Uganda and Rwanda are both societies in transition  — transition away from conflict, transition toward greater political participation, transition out of poverty. How today’s children will view the behaviour and policies of leaders whose life experiences are increasingly distant from their own is yet to be seen. It may be too soon to detect generational differences in any scientific way, but ready or not, the youth bulge is coming into its own. Young people already make up the lion’s share of the population in the region. In just a few years they will be the king and queen-makers, or breakers. Watch this space.

The UNSC: Performance and Perceptions

Published online February 16, 2012.

The actions (or inactions) of the United Nations elicit varied reactions. Supporters hold the institution in high esteem, and believe it has the power to promote peace, human rights, justice, and social progress, as the preamble of its charter suggests. Even the most ardent enthusiast will admit that the UN is not a perfect institution, but argue instead that it is as close to a functioning world government as we can hope for in this period of our history.

To others, the UN is a bumbling, impotent and ineffectual player in the realm of international relations. It is an expensive bureaucracy that both overreaches and underperforms. Critics cite inaction during crimes against humanity on the one hand, and intrusion of state sovereignty on the other. They argue that decisions are dictated not by the community of nations but the community of a few superpowers.

On either side of this chasm, and everywhere in between, are people who do not understand how the organization works. What most people see, if they see anything at all of the UN, are its loud condemnations, the roaring silence of its passivity, or its troops scattered across the world’s “troubled” spots.

The future of the organization depends not only on its performance, but also on global public opinion. The recent failure of the United Nations Security Council (UNSC) to back the Arab League-sponsored resolution on Syria brings to light afresh the challenges the organization faces. The halting process of decision-making at a time when hundreds of Syrian civilians are being slaughtered by the Assad regime is reminiscent of past faltering by the Council. Inability to gather consensus on resolution wording, much less action, has hampered the UNSC on many occasions.

UN intervention during the Rwandan genocide is only the most vivid example of a lumbering bureaucracy with at least as many interests as members stumbling at the feet of those who clamor for its attention, resources, and even salvation. An excruciating recollection of the events of the UN’s behavior in 1994 calls our attention to the power of a few words. What is said and not said, done or not done, leaves a mark on history, on leaders, and on ordinary citizens that cannot be removed.

It is not at all surprising, therefore, that according to the World Values Survey, only 8% of Rwandan respondents thought that policies regarding international peacekeeping should be handled by the United Nations. The remaining 92% thought peacekeeping should be handled by national governments or regional organizations. This response varied drastically from almost all other countries surveyed. On average, nearly 50% of people in nearly 50 countries around the world thought the UN, and not regional organizations or national governments, is best placed to handle international peacekeeping. Rwanda’s experience with peacekeeping operations has clearly damaged trust in the UN in this arena.

On the other hand, a greater percentage of respondents in Rwanda than in any other country think the UN is best placed to handle refugees. Only 10% of Rwandans thought national governments should handle policies related to refugees, while the vast majority, 73%, thought the UN should handle refugees. Meanwhile, 32% of respondents from all other countries thought national governments should handle refugees while only 48% thought the UN was best. A more thorough investigation could uncover the extent to which first-hand experience with the UN intervention, in all of it various forms, shapes public opinion regarding what the organization can and should do.

In the meantime, the most recent failure of the UNSC to come down firmly on its position towards a regime that is clearly brutalizing its population raises questions about the limits of an international institution whose explicit and primary goal is world peace. It is precisely the collapse of these talks that chips away at people’s faith that the UN, or any organization for that matter, can promote peace in any way beyond that which is lip service.

Students in a class I am helping teach this term learned this lesson the “hard” way in a UNSC simulation last weekend. For two days the fifteen delegations, made up of at least some students who are destined to be diplomats and policymakers themselves one day, met to draft and pass a resolution on the international community’s response to Iran’s nuclear program. They took turns making statements to the council, drafting the resolution, and debating each word and paragraph. It soon became apparent that delegations were not all equal. The permanent five (P5) had the unique power to make or break a deal. After nearly twenty hours of debate, the council came to the final vote.

In a bizarrely parallel universe to the actual meeting and vote of the UNSC taking place the same day, the students’ resolution was vetoed by China, a member of the P5. A collective “boo!!” filled the room. But it was over. After days of work, side deals, compromises, and urgent pleas, the resolution had failed. Meanwhile, in New York, the real Chinese and Russian delegations killed the Syrian resolution. The palpable disappointment of the students was only a whisper of the hundreds of disappointments, much larger and all too real, of both UN action and inaction.

Those who have been burned before, in ways small or large, have no choice but to alter their behavior domestically and make do with the politics in New York. The UN has proven time and again that it is not an organization that leaders or publics can rely on when times get tough. Whether or not a resolution can be reached depends not only, not primarily, on the gravity of the situation at hand, on the peril at which lives are placed, or on the number of lives in danger. Instead, alliances, precedents, and power creep into the corners of debates between great and small countries, and the diplomats that represent them.

The ongoing perils of childbirth

Published online February 1, 2012.

A problem of supply in services is limiting further improvements in maternal health

Fertility rates in Rwanda have been falling steadily over the past several years, but this year close to 400,000 Rwandan women will become pregnant and give birth. Next door in Uganda, four times as many women will become pregnant, approximately 1.5 million. If recent trends hold, nearly 10,000 of these women will lose their lives during or shortly after their pregnancy. Many of them will suffer from bleeding and infections that can be treated or prevented.

Surveys show that pregnant women in both Rwanda and Uganda seek antenatal care at very high rates. Nearly 98% of women in Rwanda and 95% in Uganda have at least one antenatal visit during their pregnancy. These women want information about their pregnancy, and seek out health services that they believe will help them have healthy babies. But often the health system fails to provide these women with the information they need to take care of themselves, and far too many mothers lose their lives because they do not receive emergency care in time. Rwanda has been showing steady progress in improving maternal health, but Uganda has faired poorly.

Both Uganda and Rwanda continue to have high levels of maternal mortality, defined as the death of a woman while pregnant, or within 42 days after the termination of pregnancy (excluding accidents). Between 1985 and 1995 in Uganda, maternal mortality was estimated at 527 deaths per 100,000 live births. The following decade, from 1996 to 2006, maternal mortality was estimated at 435 deaths.Although these figures suggest a slight decrease over the past twenty years, the margin of error around these estimates are such that we cannot say with any confidence that maternal mortality rates have changed at all between 1985 and today. Thus, it appears pregnant women in Uganda today are equally likely to die in childbirth as they were 25 years ago, when the National Resistance Movement came to power.

Meanwhile, maternal mortality in Rwanda has fallen significantly, although rates in Rwanda have for some time been higher than those in Uganda. Between 1995 and 1999, maternal mortality in Rwanda was estimated at 1071 deaths per 100,000 live births, one of the highest rates of maternal death in the world. Between 2000 and 2004, however, it had dropped to 750. The most recent estimates should be available in the next year or so, and are likely to show even further decline.

Rwanda may have made greater strides than Uganda in reducing maternal mortality in the past decade or so, but both countries face significant challenges in improving maternal health. There is a long way to go. The good news is that unlike many types of preventive health behaviors, such as getting immunizations or sleeping under a bednet, seeking help during pregnancy has become very common, even natural. In other words, the demand for health care during pregnancy appears higher than for many other health issues. Unfortunately, while demand is high, supply of care during pregnancy is weak.

Although nearly all pregnant women seek antenatal services at least once during their pregnancy, not all clinics and health facilities are equipped and ready to meet their needs. In fact, most health facilities are lacking the basics when it comes to antenatal care. The Service Provision Assessment Survey 2007 found that only 31% of health facilities in Rwanda had all the items required for infection control, including running water, soap, latex gloves, and disinfectant, and only 28% had all the essential supplies for basic antenatal care, including iron and folic acid tablets, tetanus vaccines, and equipment to measure blood pressure. A mere 11% had all the medicines required to treat pregnancy complications, including antibiotics, antimalarial drugs, and medication to treat common sexually transmitted infections.

To make matters worse, very few women were given sufficient information so that they could take good care of themselves at home during their pregnancy. Only 8% of women in Rwanda were told about signs of pregnancy complications, while only 35% of women in Uganda were informed. It is perhaps not surprising that only 35% of Rwandan women and 47% of Ugandan women attend the recommended four antenatal visits. When women arrive in clinics, often without power or water, which do not provide the necessary equipment and information to help them with their pregnancy, there may be little incentive to keep going back.

Of course, the news is not all bad. On the contrary, the improvements that have been made in maternal health, particularly in Rwanda, are extraordinarily impressive. In just five years, between 2005 and 2010, the percentage of mothers whose delivery was assisted by a trained and skilled provider increased from 39% to 69%. The percentage of mothers who delivered in a health facility jumped an equally miraculous 28% to 69%. The increase in births under the watch of a skilled provider has likely played a large role in the reduction of maternal mortality. An estimated 15% of all pregnant women will encounter life-threatening complications, and trained nurses, midwifes, and physicians can help make sure these complications do not become fatal.

The fact that pregnant women appear to seek out services and information at high rates is a great opportunity for public health, but this opportunity is squandered if health facilities are poorly equipped to provide care. While Rwanda has made strides in improving the supply of care, there is less evidence of improvement in Uganda. The results speak for themselves.

Rwanda’s next president

Published online January 16, 2011.

There was quite a kerfuffle following President Kagame’s last visit to Uganda in December 2011. The hoo-ha that played out over the airwaves, news pages and Twitter had nothing to do with the trip per se – relations between Presidents Kagame and Museveni have been warming over the past six months and such visits are becoming the norm – but rather with repeated questions about presidential term limits in Rwanda. Amending the constitution to lift term limits is a relatively new trick in the handbook of institutional manipulations. President Museveni, together with the Ugandan parliament, steamrolled right through term limits in 2005, paving the way for a 30-plus-year reign for the former rebel leader. By the time Uganda marks its Jubilee in October of this year, just a few months after Rwanda’s 50-year celebration, Yoweri Museveni and the National Resistance Movement will have held power for over half of the post-independence period.

Whether or not Kagame will attempt to follow in the footsteps of Museveni and lift term limits in advance of the next presidential elections in 2017 is a tired argument. Personally, I doubt that he will do so, but neither do I think it would be at all a difficult task. But that is neither here nor there. Just as there will be a South Africa without Nelson Mandela, there will be a Uganda without Museveni and a Rwanda without Kagame. Though there will undoubtedly continue to be discussion regarding Kagame’s candidacy up until 2017, ultimately the more productive debate is the extent to which promising and talented individuals have opportunities today to become tomorrow’s leaders.

I’m not going speculate who the next president will be, but I’d like to float the idea that Rwanda’s next head of state will be a woman. Rwanda has led the way in bringing women into politics and positions of power, and women around the world are making inroads every day into politics, business, academia, and beyond. As in Uganda’s National Resistance Army and Movement (NRA/M), women have held key positions in the government and party of the Rwanda Patriotic Front (RPF). The presence of women in politics has been steadily increasing since 1994, and in 2003 Rwanda joined Uganda, Namibia, Mozambique, South Africa, and several other countries in implementing a gender-based quota for legislative seats. In the 2003 election, women won nearly half of all seats in the legislature.

Women have also been well represented in other areas of government and civil society in Rwanda, and have played key roles in rebuilding society in the aftermath of the genocide. Many women have been elected gacaca judges, and women groups have worked to address a wide array of issues, from health to microfinance. As of 2008, Rwanda is home to the only majority female parliament in the world. Women today hold several key ministries, including the Ministry of Foreign Affairs (Louise Mushikiwabo) and the Ministry of Health (Agnes Binagwaho), as well as senior management positions in institutions such as the Rwanda Development Board (RDB). And regardless of your view of her, Victoire Ingabire has emerged as the figurehead of the official opposition in Rwanda.

While women representatives do not alter policy or the playing field overnight, research suggests that women’s participation in politics has the potential to affect both policy and perceptions about women’s abilities. Studies in India found that local politicians invest in public goods that are most important to their lives, and that types of investment differ by gender and location. For example, women tend to invest more in drinking water than their male counterparts. In Rwanda, women parliamentarians have been credited with pushing for the reform of laws regarding issues such as inheritance, discrimination against women and sexual assault.

In addition to the possibility of affecting policy outcomes, some research shows that the presence of women in politics helps to alter perceptions and prejudices about women’s ability to lead and govern. A group of researchers from the US and India found that where women in India held elected positions in local government, initially with the help of gender quotas for these positions, men tended to hold less negative stereotypes about the efficacy of women in positions of authority.

Additionally, exposure to female leaders tended to increase people’s perceptions of women’s abilities over time. Although community members may rate poorly the first woman elected to a position, her successor would generally be rated more favorably. Exposure to women in politics, at least in some settings, appears to reduce negative stereotypes about women’s abilities to govern, and will likely encourage more women to enter the ring.

In Rwanda, many women have had opportunities to develop the skills and experience to lead. While the debate on term limits rages on, it is important to think beyond personalities—however formative or influential—and focus on the processes through which leadership is reproduced. Rwanda’s political system, its many flaws notwithstanding, has allowed women to participate in government and policymaking to a greater extent than in many other countries. These opportunities for leadership will help shape the next generation and next era of Rwanda’s history. It would not be surprising, therefore, if Rwanda’s next president comes out of this network of powerful and promising women leaders.

Women’s leadership in Rwanda has evolved alongside the innovative approaches the country has tested in its recovery from conflict. Like other challenges Rwanda faces, both general and gender-specific, from poverty to maternal mortality, it is to processes and not individuals that attention should be paid.  Despite urgent challenges, real opportunities exist for ordinary citizens, men and women alike, to grow up in good health with a good education. The impact of public health and education policies on Rwanda’s political development may not be obvious now, but will eventually become evident. The democratic space in Rwanda is still being tested and shaped, discussed and critiqued, pushed and pulled. Ultimately the future lies not with an individual, but with a system that allows the next generation of leaders to emerge.

What is the (global) village gossiping about?

What is the (global) village gossiping about?

Published online December 22, 2011.

Accessing people’s thoughts and interests from Asia to Africa is just a click away

It used to be that education primarily took place in a classroom. These days, the chalk and blackboard are fading away and steadily being replaced, or at least complemented, by new technology. Even in some of the world’s hardest-to-reach places, cell towers and solar-charging stations are re-inventing the learning and communication experience. Alongside the traditional classroom teacher are laptops and cell phones, paving the way toward a whole new way of seeing the world.

A world of data is at your fingertips, quite literally. The advent of personal computers and increasing interest in making information open and accessible to all means that we now have the ability to answer many questions faster and more accurately than we ever thought possible. Information on everything from economic growth to weather patterns to flu outbreaks is just a Google search away.  Data and data sources are not without their flaws, but we can often see broad patterns much more clearly across and within countries than we once could. The question is, how can we take advantage of new and ever increasing sources of information? Perhaps one of the most novel uses of data pieces together the wisdom of the crowd. In particular, Internet search terms are an amazing guide to all sorts of phenomena we care about, including public opinion on politics and policies, investment interests, and even trends in infectious disease.

What kind of information are people searching for? What are the questions to which they seek answers? One can of course look at broad trends in search engine search terms across countries, something similar to looking at words and topics that are “trending” on Twitter, but one can also look for more specific information. How many people in the U.S., Europe, or Asia look for information about Rwanda, for example? What kind of information do they look for? Google Insights for Search can help answer these kinds of questions, and reveal interests from potential investors, tourists, and others that can be useful to the local business community, government, civil society, and individuals.

If you look at the most frequent search terms related to “Rwanda” used by those living in the United States, France, or even China, you’ll find that most are related to the genocide or the movie, Hotel Rwanda. Within the U.S., searches for “Rwanda genocide” spike every April and May, although the spikes are becoming smaller over time. This is some indication that while the world still heavily associates Rwanda with genocide, this association is becoming weaker with time. Searches for “Rwanda safari” or “Rwanda gorillas” increased greatly in 2005 and 2007 respectively, and most of these searches came from individuals living in the United States or the UK.

Meanwhile, searches about Rwanda in the East African region show a very different pattern. The top three search terms about Rwanda from those living in Uganda and Kenya are all related to jobs, and primarily come from three cities, Kampala, Nairobi, and Mombasa. Meanwhile, searches from within Rwanda about Uganda focused on news outlets, such as the Daily Monitor, New Vision, and “news Uganda” more generally. The most common searches in Rwanda about Kenya include Kenya Airways, the Daily Nation, and Kenyan universities.

Understanding search trends can be useful for businesses and entrepreneurs, but they are also a cheap and easy way to do public opinion polling. In the U.S., search trends of the past couple of months have tended to mirror official polling trends for presidential candidates in the Republican party, for example. If you look over time, you can see the rollercoaster levels of support for candidates such as Rick Perry, Mitt Romney, Herman Cain, and Newt Gingrich. In the U.S., regular and nationally representative polls are conducted throughout the campaign period, but the more informal “search” polling can be very informative as well, and far less expensive.

One challenge for using this type of data in countries like Rwanda and Uganda is that relatively few people are online, although the number of internet users is growing by the day. In Rwanda, approximately 13 percent of people accessed the Internet in 2010, up from 7.7 percent in 2009, according to the International Telecommunication Union. More and more people are using their mobile phones, rather than computers, to access the Internet, which makes it easier to get online. Although there may not be enough people using Google to get a good measure of public opinion in Rwanda, this will very likely be possible in the not-too-distant future.

Already, one can observe trends in public interest in politicians among those living in capital cities. Searches for “Besigye”, Ugandan President Yoweri Museveni’s archrival, spiked within Kampala in November 2005, a few months prior to the heated 2006 presidential election, and spiked again to a lesser degree in February 2011, during the most recent election. It appears there was much more interest in Kizza Besigye leading up to the 2006 election (even with considerably fewer people online) than during the time leading up to the most recent elections, a trend which was reflected in Besigye’s support on election day as well. Online searches for Besigye spiked again in April, during the Walk-to-Work protests, but unfortunately for the repeat presidential candidate, by then the election had already passed. Despite the limited connectivity of the population living in Uganda, general election trends were evident in people’s online behavior.

Searches for "besigye" in Uganda, 2004-2011

Finally, search terms can be useful for tracking trends in infectious disease. When people fall sick, they often turn to the Internet for information about their symptoms or illness. Tracking search terms can thus identify and follow outbreaks of particular types of illnesses. Google Flu, for example, uses data on search terms to estimate trends in the spread of the flu virus. Again, their data is best for countries in which the majority of the population has access to the Internet, but as Internet connectivity increases in countries like Rwanda and Uganda, crowd-sourced data on infectious disease may help health officials identify and address outbreaks.

The wisdom of the crowd has for long eluded policymakers, investors, and even public health experts because it is costly to collect information from a large number of people, and people often have incentives to misrepresent their interests and beliefs. Using search trends, however, as one measure of people’s interests, opinions, and concerns, is one way to crowd-source information gathering in a relatively inexpensive and expedient manner.

HIV in colonial Africa

Online this week in The Independent (Rwanda Edition): How public health efforts likely contributed to the early spread of HIV.

The Tragic Amplifier

Published online December 8, 2011.

This year marks the 90th anniversary, approximately, of the introduction of human immunodeficiency virus (HIV) into the human population. It also marks thirty years since HIV was first scientifically recognized in 1981. Since the 1920s, this virus has spread across the globe and become the HIV/AIDS pandemic we are all too familiar with today. Most people consider the 1980s to be the beginning of the HIV/AIDS pandemic, but the virus had been prevalent in populations living in parts of central Africa for decades before it became a global nightmare.

New evidence from epidemiologist and international health expert Jacques Pepin suggests that human efforts to improve public health in central Africa were critical in facilitating the early spread of HIV, which has since claimed nearly 30 million lives. In the past two decades, massive coordination, mobilization, innovation, and investment have managed to slow the epidemic and save millions. As we mark World AIDS Day on December 1, 2011, HIV/AIDS is a reminder to us all of the tremendous power of human folly, but also of human triumph.

The Origins of AIDS, by Pepin, is a remarkable new book that pieces together the emergence of HIV in the human population, and its subsequent spread across the globe. HIV is the human version of simian immunodeficiency virus (SIV), which has been present in chimpanzee populations of central Africa for hundreds of years. Human contact with chimpanzees led to at least one transmission of SIV to HIV in a human in the early 1920s, most likely a hunter or a cook living in central Africa, where the majority of SIV-carrying chimpanzees live. This transmission alone was extremely unlikely to have triggered an HIV epidemic, and indeed chimpanzee-to-human transmission could have occurred on separate occasions prior to the 1920s, but would not have spread far. An infected hunter may have passed HIV to his family members, but in all likelihood, the virus would have stopped there. Why did HIV begin to spread beyond a few infected individuals in the early 1920s?

Pepin argues that heterosexual transmission, which is the predominant mode of transmission of HIV today, could not alone have led to an outbreak of HIV on a scale that would trigger a pandemic. Thus, there must have been some kind of “amplifier” that allowed for very rapid transmission of HIV to many people at a time. And what was the mostly likely initial culprit in the amplification of the virus? Colonial public health campaigns involving widespread use of unsterilized syringes and needles.

In the 1930s and 1940s, colonial administrations in French Cameroon, the Belgian Congo, and elsewhere began massive public health campaigns to treat various infectious diseases, including yaws, syphilis, malaria, leprosy, and sleeping sickness, using syringes and needles which were not sterilized regularly, if at all (oral tablet versions of treatments were not available for these diseases at the time). Although there are no blood samples from this time period still in existence (the oldest blood sample in which HIV has been detected dates back to 1959, taken from a man living in Leopoldville, Congo, now known as Kinshasa), it is well documented that other less lethal viruses, like Hepatitis C, were transmitted via syringes in Cameroon, Gabon, and the Belgian Congo, among other colonies. It is not difficult to imagine that HIV could have been passed quickly through a population via syringe as well.

One clinic to treat sexually transmitted diseases (STDs) in Leopoldville treated up to 1000 patients a day by the mid-1950s, with documented evidence that medical equipment was not sterilized between patients. To make matters worse, HIV was likely introduced into Leopoldville/Kinshasa at a time when there was a dramatic gender imbalance due to colonial policies. Urban areas like Leopoldville were often the equivalent of “work camps” in which wives and children were not welcome, which resulted in widespread prostitution, further facilitating the spread of HIV through heterosexual transmission.

HIV, which first spread through non-sterile syringes, often in clinics aimed at treating sexually transmitted diseases among men and sex workers in urban areas, kept at a steady prevalence through heterosexual transmission among the same population. In the colonial period, female sex workers, or “free women”, had only a few regular clients each year, but by the time of independence, female prostitutes would often see up to 1000 clients per year. This new type of prostitution greatly facilitated the transmission of HIV to populations beyond urban areas, and spread along major trades routes and cities in central and eastern Africa, including Kigali.

By 1984-85, Kigali, which at the time had a high ratio of males to females, and thriving prostitution, had the highest recorded HIV prevalence in the world, with 80 percent of prostitutes, 50 percent of STD patients, and 15-20 percent of blood donors, factory workers, and hospital employees testing positive for HIV. By 1987, HIV prevalence was at 17.8 percent in urban areas and jumped to 27 percent in urban areas by 1996.

From central Africa, HIV soon spread to Haiti, before being transmitted via multiple routes to the United States and beyond. Today, 34 million people are living with HIV/AIDS, and another 29 million have perished. That the spread of this virus was likely facilitated, and perhaps only possible, with the help of human technology and early public health campaigns should give us pause, and remind us of the terrifying potential for destruction due to human folly. As Pepin writes, “When humans manipulate nature in a way that they do not fully understand, there is always a possibility that something unpredictable will occur.”

Turning the tide on the spread of HIV/AIDS has taken decades, and millions have tragically lost their lives in the process. But the HIV/AIDS epidemic also demonstrates the amazing power of human innovation and cooperation that can take place on a global scale. Today, there are 6.6 million people receiving life-saving antiretroviral treatment, and both AIDS-related deaths and new HIV infections are declining in most parts of the world. The time, research, energy and money that have gone into tackling HIV has been phenomenal. If anything, we are now in danger of devoting too few resources to other health challenges that must also vie for the attention of the global health community and domestic health budgets.

HIV/AIDS is an extraordinarily painful reminder of the good intentions that can pave the road to hell, and of the unique capability of humans to create as well as destroy.

HIV/AIDS: Human folly and triumph

Today is World AIDS Day. HIV has taken the lives of an estimated 29 million people around the world, and currently around 34 million people are infected. The effort of many individuals, organizations, and governments has led to a turnaround in the pandemic, infection rates and deaths due to AIDS are falling in most parts of the world. Still, there is a long way to go, and many people still do not have access to life-saving drugs.

A new book by Jacques Pepin, The Origins of AIDS, provides a remarkable account of how HIV initially spread among populations in central Africa, and later became the pandemic we know today. His sobering finding is that human efforts to treat and prevent disease with the use of non-sterilized syringes in colonial Africa very likely facilitated early and rapid HIV transmission. I discuss his work in this week’s column, excerpts of which is below.

HIV/AIDS: Human folly and triumph (published in this week’s Independent Rwanda Edition)

This year marks the 90th anniversary, approximately, of the introduction of human immunodeficiency virus (HIV) into the human population. It also marks thirty years since HIV was first scientifically recognized in 1981. Since the 1920s, this virus has spread across the globe and become the HIV/AIDS pandemic we are all too familiar with today. Most people consider the 1980s to be the beginning of the HIV/AIDS pandemic, but the virus had been prevalent in populations living in parts of central Africa for decades before it became a global nightmare.

New evidence from epidemiologist and international health expert Jacques Pepin suggests that human efforts to improve public health in central Africa were critical in facilitating the early spread of HIV, which has since claimed nearly 30 million lives. In the past two decades, massive coordination, mobilization, innovation, and investment have managed to slow the epidemic and save millions. As we mark World AIDS Day on December 1, 2011, HIV/AIDS is a reminder to us all of the tremendous power of human folly, but also of human triumph.

*                   *                   *

Turning the tide on the spread of HIV/AIDS has taken decades, and millions have tragically lost their lives in the process. But the HIV/AIDS epidemic also demonstrates the amazing power of human innovation and cooperation that can take place on a global scale. Today, there are 6.6 million people receiving life-saving antiretroviral treatment, and both AIDS-related deaths and new HIV infections are declining in most parts of the world. The time, research, energy and money that have gone into tackling HIV has been phenomenal. If anything, we are now in danger of devoting too few resources to other health challenges that must also vie for the attention of the global health community and domestic health budgets.

HIV/AIDS is an extraordinarily painful reminder of the good intentions that can pave the road to hell, and of the unique capability of humans to create as well as destroy.