Do You Realize?

I like routines

2011-07-27T16:10:00.000-07:00

I really like routine. Actually, I get really comfortable in routines - some routines I like (glass of wine with dinner, watching Louie on Thursday nights, brushing my teeth in the car), others not so much.

Anyway, today I broke my routine. I don't have a ton to do at work at the moment - what we consultants call "being on the beach". I hear at the top firms folks actually go to the beach during these breaks. I just watch HBO GO at my desk.

So my routine is already messed up (not working hard). I decided to use some of my now very free time productively, so after lunch I went to the gym. Fine. Did 40 minutes of elliptical and some squats, if you must know. So now after work, which is when I usually (at least for the past 3 weeks) go to the gym, is now open. I decide to get a haircut.

My hair cut spot is Brighton's Hair Salon, which is in the neighborhood I lived in from 2008-2009. Again, routines. I get to the place, find parking quick, pause the podcast (Marc Maron) on my iPhone, and go inside. I have to wait 20 minutes for the guy ahead of me. Then Sofia, who runs Brighton's Hair Salon, sits me down and does a great job making me look presentable and professional. Great.

Next I run into the beer & wine grocery store and grab a Montepulciano and Cupcake Chardonnay. Also some "owater" because they don't have Vita Coca.

I head back to my car and as I turn the corner I can see through the window that the dashboard is lit up with electronics. What?

My car is sitting in the middle of Brighton, running in park. I get in and check to see my laptop is still in its case. Hallelujah, I'll survive another day!

I like routines.

The Debt Limit

2011-07-06T10:20:00.000-07:00

I found what Ronald Reagan had to say about the debt limit very instructive on how ridiculous the GOP has become:

"This letter is to ask for your help and support, and that of your colleagues, in the passage of an increase in the limit on the public debt...The full consequences of a default - or even the serious prospect of a default - by the United States are impossible to predict and awesome to contemplate."

Read it all here: Washington Post.

The man he was writing the letter to, Majority Leader Howard H. Baker, has a very cool Wikipedia article: Howard Baker

Herman Cain vs. Bill Clinton

2011-01-18T07:37:00.002-08:00

Herman Cain is a very likely GOP candidate for President in 2012. He's been getting a bit of news on the interwebs recently. This video has been making the rounds today:

I decided to make a spreadsheet response, which allows you to mess with the assumptions. Based on my analysis, it looks like the upper end impact on Godfather's Pizza's profits would be -5% (1.5% profit to negative 3.5%). However, there are a number of ways Godfather's would likely mitigate the impact of this.

But don't take my word for it, check out the spreadsheet yourself: Cain vs. Clinton HCR Debate - Impact on Godfather's Pizza

Feel free to email me and I'll send you a copy: michael.b.s.rossiter@gmail.com

I'm Baaack...

2011-01-18T07:37:00.001-08:00

At least posting a few things as they catch my fancy.

Do You Realize?

2009-12-17T21:44:00.002-08:00

I’m leaving Rwanda today. It will certainly be hard to leave such a talented, passionate, fun team and such an important project. I've learned a lot being here.

Management Lessons

2009-12-17T06:57:00.005-08:00

As CCHIPs assessed health centers for expansion, we visited nine of eleven health centers. Our visit to Murandi was eye opening. Murandi has no NGO support and yet it is THE model health center.

As the Titulaire of Murandi tells it, two years ago he sat the staff down and they set a goal: to be the best health center in Musanze District. They organized a PBF committee to implement improvements to get a higher score on the Performance Based Funding (PBF) evaluation. Other committees regularly meet to coordinate other improvements. The staff even decided to forego some of their personal PBF bonuses to use the money to improve the health center.

Essentially, Murandi has a functional management structure. The structure allows it to identify problems and implement improvements.

Zack and Jeanne d’Arc decided it would be a good idea to get the Shingiro staff together with the Murandi staff. We wanted to see if some of the spark at Murandi might rub off on Shingiro.

So on a Thursday afternoon we picked up ten members of the Shingiro staff. We brought key personnel – the Titulaire, the Adjunct Titulaire the Accountant, the Data Manager, the Cashier, the Mutuelle Accountant – all of the key management people that we needed to take more initiative.

The drive to Murandi is gorgeous, driving up and up through the hills.

On the ride, Zack talked a lot about how great it would be for the Shingiro staff to see the Murandi staff at work, “We need to implement improvements at Shingiro based on the Murandi model as quick as possible.”

After introductions, the staffs paired with their counterparts. I followed Marie Josee, the Shingiro Accountant, and Desiree, the Murandi Accountant. Desiree showed Marie Josee how he calculates the daily balance in his computer, how he checks it with the Mutuelle office, and how he manages the work of the Cashier. It was a really impressive system: efficient and accurate. The staff had clearly spent a lot of time and effort thinking about and implementing the best way to do the accounting.

I thought about the importance of the visit: If we could show the Shingiro staff the benefits of how Murandi functions, we might convince them to adopt the same management systems.

Instead of spending months making iterative improvements, we found a model that works now. If Shingiro could implement it quickly, it might save a lot of time: probably the most effective way to turn a weakness into a strength is to identify the strongest performer and copy what they do.

There is a strong counterargument to this position, which advocates fixing a recognized gap in performance by improving slowly in steps that lead to the ultimate goal.

…

I wrote the rough version of the above right after the trip to Murandi, in early October. I didn’t post it or expand on it at the time. I tried. But I felt like there wasn’t enough to say. We didn’t know what the true result of the trip would be. I didn’t know which side of the debate to take: the radical or the iterative approach to developing management systems.

At the time, the choice seemed binary – either the management team could identify areas for improvement and take slow and steady steps toward improvement or it could implement radical improvements based on a successful outside model.

After working with the Shingiro management team for several months, I’ve come to realize that the choice is not binary. The choice is not even particularly important. What is important is the capacity to recognize and implement the appropriate approach depending on the needs of the moment.

Three months after the visit to Murandi, Shingiro does not have the Murandi-type management systems in place: the accounting is still a bit of a mess, there is no PBF review committee, the Pharmacy management isn’t as good as it should be. Zack’s goal to quickly put the Murandi systems in place before the Shingiro staff forgot them could not have been done under the circumstances. At the time of the Murandi visit, Shingiro did not have a management structure that was capable of implementing much of anything.

…

The CCHIPs approach is to work closely with health center staff to help them develop their own solutions to problems. In this way, solutions will be thoroughly understood by those applying them and the staff will feel a sense of ownership and control over how the health center operates.

At the beginning of the project, both Zack and I made the mistake of trying to create ‘tools’ for the health center staff that are extremely user-friendly. For example, Zack developed an Excel accounting workbook. I developed a database for health data – just put the data in here and presto!, all set.

Both of these tools failed. Zack and I assumed that by locking formulas and making it very clear where to input the figures, the Shingiro staff couldn’t mess up our perfect workbooks.

But, of course, they could and they did.

Even more importantly, the Accountant didn’t understand how the income and expenses link together to create and follow a budget and the Data Manager couldn’t interpret the output of the health database. Without the understanding of why the tool was useful, neither tool had much value.

We decided we needed to give the staff a more comprehensive understanding of the logic underlying the tools, so that, if they chose to do so, they could create the tools themselves.

What we realized is that to impart real and lasting change, you need to help a manager develop the capacity to ask ‘why?’ Our managers must have a comprehensive understanding of the systems that they are managing. Without a comprehensive understanding of how processes fit into the wider scope of health center operations, the health center cannot respond to change and its managers cannot recognize areas for improvement.

There are mechanisms out there, like surveys of health centers that help managers to identify areas for improvement at the health center level. These tools can be useful. For example, we were excited to visit Murandi because they do extremely well on the surveys. But the surveys rely on outsiders to identify areas for improvement. Outside standards cannot be as effective as expert managers that are deeply engaged with their own health center operations.

As we continued to work at Shingiro, we came upon a vital insight:

Empowered managers ask questions. These questions lead to an understanding of why things are the way that they are. On the basis of that understanding, managers can proactively develop plans to optimize operations.

At the time of the Murandi visit, there was no structure to facilitate the process of questioning to understanding to action. Shingiro needed a management structure to facilitate the implementation of such a decision.

A strong management team can identify areas for improvement and address them through iterative solutions OR by importing a system from outside. The team can mix and match strategies because they have the capacity to understand problems and develop the right solution.

Murandi showed us that our efforts are possible. Murandi proves, beyond a doubt, that Rwandans can manage themselves, that our efforts are not in vain. Not that we doubted that. But it was powerful for the Shingiro staff to see it.

In response to this problem, Zack has worked very hard to develop and implement a new management structure at Shingiro.

Under the old system, every employee directly reported to the Titulaire. When CCHIPs arrived at Shingiro health center, there were only about 10 nurses. However, as the staff has grown to about 20 nurses, this arrangement has become completely ridiculous.

Additionally, no one was responsible for the management of any particular Specialty. Technically the Titulaire was responsible for ensuring the Pharmacy was fully stocked, that the vaccine cold-chain was maintained, that Wound Dressing had gauze, that HIV/AIDS had retroviral drugs, and so on. In reality, this meant that in some Specialties individual nurses took responsibility and in other Specialties there was chaos. There was no way to ensure that equipment was not missing, that the files were not out of order, and so on.

Inevitably, such as system only had enough capacity to ensure the health center was running OK. The Titulaire would have needed heroic personal strength and no need for sleep to implement and monitor any changes.

So it’s no surprise that the Titulaire is a huge fan of the new management structure.The new structure is not particularly innovative or complex. It doesn’t need to be – it just needs to work. There are two major components of the new system:

There is now a level of management between the Titulaire and each Specialty. Four nurses serve as Service Managers who report to the Titulaire. Each Service Manager is responsible for their Service – Curative, Preventative, Promotional, and Administrative.
Each Specialty has a Specialty Responsible - one nurse accountable for the operation and improvement of each Specialty. The Service Responsibles report to the Service Managers.

During the orientation of the new managers, Damascene, the new Curative Service Manager, said, “Woah, I’m responsible for so many people now – in Reception, Consultation, Wound Dressing, Pharmacy, and the Laboratory.”

To which Felicien, the Titulaire, replied, “Yeah, imagine how I felt directly managing all of those Specialties and all of the others.”

At the Specialty level, the Specialty Responsibles are now motivated to improve their Specialties. The Responsibles know that they have the support of the Service Managers to implement lasting improvements. And when the Service Manager needs feedback from the Specialty level, the Responsibles can provide upward perspective.

This structure gives the Titulaire and Service Managers the time and space needed to set direction. It increases the capacity of the management structure because the Titulaire is no longer solely responsible for identification, implementation, and monitoring.

…

Over the last two months since the new structure was put in place, it has been amazing to see how quickly the health center has begun to do things for itself. The new management system created the institutional capacity to be proactive.

The Titulaire and the Service Managers meet regularly, without CCHIPs’ presence. They have been able to create

Based on their experience as nurses, the Service Managers identified the problem of nurses sleeping on night guard duty. The Titulaire, Felicien, and the Curative Service Manager, Damascene, coordinated the staff to relocate the Child Consultation room and use the old Child Consultation room as a Night Guard room. This lets the night guard nurses sleep when there are no patients but they are close to where patients arrive for help.
The Service Managers noticed that the hand-washing facilities were insufficient. Based on the system developed at Murandi, Felicien and the Service Managers designed and oversaw the construction of new hand-washing points at Shingiro.
I have worked with the new Preventative Services Manager, Aggripine, to improve the filing and patient follow up systems in Preventative Services. We collaborated with her and the Family Planning Specialty Responsible to reorganize the filing system in Family Planning. Now Aggripine will be able to oversee the implementation of similar systems in Antenatal Counseling, Vaccination, and HIV/AIDS.

The new management structure allows the health center to identify problems, to understand why the problems exist, and to develop and implement solutions. Whether those solutions are big changes or small ones, developed at Shingiro or elsewhere, the important thing is that those solutions will be implemented successfully.

Thanksgiving

2009-12-12T07:38:00.001-08:00

Around 6 PM on the Sunday before Thanksgiving, I sat on the front porch of the project house, reading. Zack, Amber, Consolate, and Gabby pulled up in the Land Cruiser. They had just been to Kigali to drop Dr. Cairo off at the airport.

Emi, the house dog, was VERY excited as they pulled up, because she could smell the turkeys. The team had picked up the turkeys from a farm just outside the capital. To transport the birds home, the farmer had stuffed the turkeys into white plastic trash bags. Now the turkeys sat in the back of the Land Cruiser, falling over themselves as they tried to get out of the bags.

We found that the birds could live comfortably in the gatehouse, which Muzehe (literally “old man”, our gatekeeper) never uses – he prefers to hang out in his room in the house. For a couple days we fed the turkeys corn and millet and Emi tried to find a way to break into the gatehouse.

On Tuesday night we decided it was time. Zack, Rene, and I myself took turns through three positions: holding down the bird, sarcastically commenting on the struggles of the butcher, and removing the head from the turkey. I was first up at severing the head.

Everything I’ve seen about killing poultry has indicated that one strong, quick blow across the neck will remove the head. Rene held the turkey down, and I raised the knife.

We did not have many options for which knife to use. Most of our cutlery is oriented towards chopping vegetables. We don’t boast a full-scale kosher kitchen. So, after reviewing out limited choices, we settled on the chopping knife. The chopping knife has the big flat blade and a good amount of weight. It is particularly useful for scooping chopped vegetables into stir frys.

I brought the blade down, finding that same blank state of mind that I’ve used in the past on the rugby field. It’s comfortable in its certainty. The mental state is sustainable only just before impact. It relies on the conviction that ‘I will break through and cannot be stopped’ to power complete effort of force.

Almost as soon as the knife hit the turkey’s neck, I was shocked to discover it bouncing back up. There had been no effect. I tried again.

“No! No! No!” yelled Rene, “you must saw it off!”

The chopping knife was not serrated and therefore miserably suited for such a job. I pressed the knife down, sawing back and forth.

After a few seconds, with no obvious progress I looked up, “We need a different knife!” I yelled desperately at Zack, who began to laugh. The whole point of the quick chop is that it is humane – the suffering is minimized. But here I was, standing over an animal that I intended to kill, it knew I intended to kill it, and I was doing a very bad job of it.

I crouched down again and continued to saw. Now I cut into the neck, drawing blood. It bubbled up from the wound, warm and sticky, coating my hands.

My goal was still to minimize suffering. The actual spine was proving difficult to cut through, so I focused on severing the windpipe and main arteries – removing whatever connections I could from head and body. I saw the outlines of the windpipe under the skin of the neck. I slipped the blade between the spine and the windpipe and pulled the blade up and out, severing it. But the bird continued to try to breathe, and now I could hear rasping coming from the exposed windpipe.

Finally, the knife found a notch in the spine. I pressed with my force, and pulled on the head. The spine cracked and I cut through the last bit of skin connecting the head to the body. I stood up. The turkey’s head was in my hand and its lifeless body lay on the ground beneath me.

“Ugh,” I threw the head down on the ground. I was shaking a little bit, jacked up on adrenaline. “Wow,” I chuckled, “that was ridiculous.”

Rene went next, with Zack holding down the bird.

Rene was much more experienced and efficient than I was, and the turkey’s head came off after only 10 or so seconds of sawing. However, Rene had cut very close to the base of the head, and this particular turkey was not totally ready to die.

Zack held down the turkey as it began to flap its wings.

“Don’t let go,” said Rene, “it might fly away.”

At that moment, the neck, which Zack was not holding down, turned up and looked Zack in the face. It then began spraying blood…everywhere.

The turkey flapped and flapped and sprayed and sprayed. For two minutes Rene and I howled with laughter and Zack continued his grim task, holding the turkey down as it sprayed him with blood.

Zack was to kill the last turkey and it was my turn to hold the bird down. Having studied my and Rene’s approach, Zack pulled the head firmly away from the body and quickly sawed through the neck. Learning from Zack’s experience, I held down the body with one hand and pinched the neck down to the ground. The body struggled for about a minute, then went still.

The next task was plucking.

Muzehe, Gabby, and I each grabbed a bird and a pot of boiling water. We poured the water over the turkeys, which blanched the feathers. They were surprisingly easy to pull out. Everyone I had asked told me that plucking is a pain, but it seemed very easy.

At first.

I looked over and noticed Gabby and Muzehe’s turkeys looked much less plucked than mine. I realized that they were being very deliberate, removing 100% of the feathers from a particular area before moving on. On the other hand, my bird now only had 5% of its feathers left, but they were scattered more or less evenly across the bird. I went back and plucked each remaining feather individually.

20 minutes later, the birds were plucked. Now Gabby and Muzehe took over completely. They first removed the stomach through the base of the neck. Then they cut into the bottom of the turkey to remove the intestines and other organs. It was fascinating to watch. Also grim.

After the birds were plucked and cleaned, we bagged them in the few plastic bags we had, and put them in the refrigerator to chill overnight.

On Wednesday morning, I fired up my computer and searched for “turkey recipe” on Google. I found a Thanksgiving turkey recipe by Alton Brown, of Food Network.

Back in my sophomore year of college, I watched a decent amount of Food Network. Alton Brown hosts a show called “Good Eats”. Alton distinguishes himself by applying ‘food science’ to his cooking methods. He thinks about how heat and chemicals interact in a dish. He clearly loves the process of cooking. He’s a quirky dude, a bit of a nerd, but his food always looks incredible.

The recipe called for the turkeys to soak overnight in 5 gallons of brined. So I got out the big pot and added salt, sugar, and spices to boiling water. I prepared several gallons of the stuff and put it in the fridge to cool.

The brine needs to stay cold to prevent any bacteria from getting the wrong idea, so I also prepped a bunch of ice. Since we only have two ice trays, this meant checking the ice every few hours, emptying ice into the bucket, and adding water to the trays to make more.

That night, I thoroughly washed out our big garbage can. I put the three turkeys in it, and then added the gallons of brine. I put a big rock in a plastic bag to keep the turkeys submerged. Then I added the ice.

Finally, I refilled the trays and went to bed.

The next morning, I boiled apples, cinnamon, and onions. I washed the birds and put them on our only cooking sheet. I added the ‘aromatic’ mixture to the bird’s cavities, coated them in olive oil, rosemary, and sage, turned the oven on, and put the birds in.

Several hour later, I dined with our team and about 20 guests (Muzungus and Rwandan friends). Even though I was exhausted from cooking all day, I greatly enjoyed the event.

…

Later, I reflected that I was very glad to have had the experience of killing the turkeys, but at first I wasn’t sure why.

Originally, I simply thought of the experience as a rejection of the hypocrisy of eating meat but never preparing it. And that’s true, but it’s not the whole story.

There are many things that we do in modern society which are removed from our natures. Sitting in an office for 12 hours a day is an obvious example. We submit to the modern life because it enables the way we prefer to live. The efficiency generated through the division of labor frees up time and resources for the things we like – a nice apartment, tasty food, a laptop, leather couches, a decent sized TV (with cable, DVR, and HBO of course), and an iPhone. But there is something lost in the efficiencies that allow us to own these things. Through the daily trudge, there can be a disconnection of life and living.

The life and living disconnection limits the joy of life. In a Platonic sense, we feed only our appetites and not our souls. There’s that empty feeling of a Sunday afternoon spent on the couch – dulling your senses before the work week begins. That’s not living – it’s surviving life.

I was glad to have the experience of a carnivore – to find an animal, to kill it, and to eat it. I watched the turkeys bleed and suffer and die before me. I felt the regret of killing, the power of taking a life, and the joy of a small task of living.

The experience increased the value and joy of the meal. I was connected – through a shared experience – to my meal. I was more thankful of the ability to be with friends and to feel alive. Zack says that the turkeys were the best he’s ever had at Thanksgiving. I suspect that’s as much related to the value of the experience as to our skills in the kitchen.

It was not pretty, it was a little bit sad, but it was a thanksfull experience – it made me happy to be living.

The whole process was very deliberate. There was joy in experiencing each of the iterative tasks – killing and cleaning the birds, preparing the brine, cooking the meal, and sharing the meal with friends. The division of labor of modern society allows us to feed our appetites without thinking too much about the joy of experiencing the whole process.

That said, I do not believe that modernity is unredeemable – we got the turkeys from a farm, we drove them home in our SUV, the recipe came from the Food Network website. Ask any of the people that use Shingiro health center if they enjoy growing their own food, preparing it and cooking it. It’s not possible in their context of extreme poverty.

The efficiencies of modern life are preferable to a life in the poverty of complete self-reliance.

But life and living are much more enjoyable when connected.

Bus to Uganda

2009-12-05T04:17:00.000-08:00

Right after Thanksgiving, we took a four-day weekend to go rafting in Uganda at the source of the Nile.

I plan to write up the experience, which was really cool. The only downsides were a deep, deep, equatorial sunburn (sorry mom) and the 12 hour bus ride each way:

Dedicated People Following Their Instincts

2009-12-04T09:08:00.000-08:00

Sometimes, in the midst of all the work I’ve been doing with CCHIPs in Rwanda, I lose track of what I’ve learned. It’s easy to lose sight of the big lessons in the day-to-day, but recently I read something that helped crystallize a thought.

I saw a blog post by William Easterly at Aid Watch. Easterly writes about his visit to a maternity and family planning clinic in Ethiopia. After only an afternoon visiting the project, he developed a positive assessment of the program. The post touched on two things that I have found to be true:

1. The key to an effective organization is the dedication of its people

2. For evaluating human resources and management, the value of randomized trials/statistical analyses is often not worth the cost (in time, resources, etc) compared to a quick site visit and the instincts of experts

Since CCHIPs is a small team, I have had the opportunity to work with the Jeanne d’Arc and Zack on management and strategic planning issues. For example, in preparation for CCHIPs’ expansion to 4 additional health centers in 2010, I analyzed the available surveys of health center performance and the health data of patients seen.

We evaluated health centers based on two dimensions: Need and Capacity. The CCHIPs team wants to work with health centers where we can have the biggest Impact – we do not want to be dropped into the worst possible situation and have little means of fixing anything, nor do we want to be dropped into the best health center and have little to fix. We want to identify health centers that have a lot of needs for help, but specifically needs that align with the expertise that we developed at Shingiro. Therefore, for the expansion presentation I wanted to quantify both the NEEDs of the health centers and our CAPACITY to address those needs.

Our capacity to help a given health center varied in three very specific ways:

Distance: A few of the health centers are very far from our project house in Ruhengeri, up to an hour and a half drive each way. If we worked with those health centers, we would use 3 hours each day just travelling to the health centers.

Public Health Centers: Some health centers are run by the Catholic Church. We expect to work with the diocese health centers in the future. But for now the Church’s veto power over potential reforms/changes/initiatives would sap a LOT of our capacity to have an impact.

Rural/Urban: We are developing a model for the delivery of primary healthcare in a rural context. The health center in Ruhengeri was not a good option.

Our capacity also varied in less specific ways. There are intangible management and human resource considerations: ‘Does the Titulaire seem professional and focused on results? How does the management communicate with the staff? How receptive is the management to our help?’ The many potential answers to these questions do not easily fall into a standard ‘check-the-box’ survey.

We visited 9 out of 11 health centers in the District to get a read on these intangibles. We considered developing a standard assessment form across each of the 5 Elements to score needs and our capacity. However, we didn’t have time to develop the standard survey before we had to choose new health centers.

So we conducted site visits and had meetings afterward to talk about what we saw.
The process wasn’t scientific. We didn’t have a standard assessment form. We didn’t even have a standard ‘de-briefing’ form. We had no definitive statistical ‘proof’ that our choices for expansion were correct.

Even so, I am 100% confident that we chose the right health centers.

I know we chose the right health centers because I know our team. We are focused. We are dedicated to our mission. We know what kind of challenges we are capable of handling.

The capacity assessments came from our guts. Our gut instincts were right because we have dedicated ourselves to understanding what we do well.

We share a mission and we are all guided by the same set of values. Because we are experts on ourselves, we can assess our capacity to create an impact accurately without the need for a standardized form. We can go to a health center, look around a bit, and get a feeling: We know whether the Titulaire wants to work hard. We can tell whether the staff is attentive to the patients. We recognize problems that we have seen before – and we know how to fix those problems.

Only a dedicated, motivated team thinks in this way. A dedicated, motivated team sees problems in the right way. A dedicated, motivated team knows how the pieces fit together. A dedicated, motivated team pulls the right levers to achieve results.
And a dedicated, motivated team can see its own values in the actions of others – we are looking for the same dedication and motivation in the health center staffs that we work with.

Maybe that focus is not there at the beginning. At no health center we saw was it fully formed or functioning. Shingiro’s getting there, bit by bit. But with a couple health centers, you saw where the shift might start. Saw small good habits already in place, a Titulaire’s unconscious consciousness.

A statistical study or analysis cannot see how everything fits together in the same way experts can. A standardized survey can’t see that spark.

This has be a big shift in perspective for me – looking for that spark. Looking for that dedication. It’s been a vital thing to learn. I remember starting work last year and trying to develop the ‘perfect analysis’ to every problem. Now it seems like such a silly goal. It’s like in econometrics: as you add more variables to a regression your model will ‘explain more’. But that model may not tell you much about what’s actually going on.

The reason you do statistical analyses is to look at things in isolation and to present challenges to your assumptions. There’s no proof in data. It can only push you towards or away from the ‘common sense’ beliefs you hold.

The more expert a team becomes, the more the ‘common sense’ thoughts will be correct.

And the only way for a team to become experts is through motivation and dedication.

I love doing statistical analyses. It is really fun to clearly show a relationship or a trend through data. But I have learned, and now I really understand, how data only carries the explanatory power of the frame you put around it.

The current perception in the District is that Shingiro is doing amazingly well. Most District officials would probably guess that Shingiro is performing much stronger on all the surveys and health data than it actually is.* Yes, Shingiro is improving across the standard surveys and in the health data but the gains are not enough to justify the highly positive assumptions in the District leadership.

However, the District’s perceptions are not wrong.

There have been fundamental improvements at Shingiro. The new management structure is far more coherent and capable. The infrastructure investments will continue to attract greater use by the community. The nutrition program is identifying and treating many children. Medical trainings and protocols are improving the quality of care. The staff feels empowered to make decisions and take the initiative to get things done. The health center is more engaged with the community and community members are beginning to use the health center more often. In short, Shingiro is a different health center than it was a year ago.

So Shingiro’s scores on the surveys and health data do not tell the story of improvement that is taking place at Shingiro. Not yet, though the improvements will no doubt be manifested in the data over time. But even then the data will never be able to tell the story of Shingiro or measure the intangible spark that’s been animated here. To see that spark, you have to drive up the bumpy clay road and take a look around.

*Shingiro ranked #1 on one key survey for the third quarter. But Shingiro still is only ranked third to fifth on the other major survey. Meanwhile, the actual usage rates as reflected by the health data are as much a function of the community’s attitudes and incomes as the quality of care provided at the health center. The health data is improving, and faster than the District as a whole, but off of a much lower base.

Ace of Base

2009-11-18T11:52:00.000-08:00

You can keep the Kigali out of the guy, but not the guy out of Kigali. We were in Kigali this past weekend to pick up our new volunteer, Dr. Peter Cairo, who has been helping us with training techniques and thinking about the project’s growth.

We picked Dr. Cairo up on Saturday and stayed over Friday night to take in more of the wonders of Kigali’s nightlife.

We sat at the Sunset Lounge, which was a nice outdoor bar. For some reason Ace of Base kept coming on, which Zack and I thought was pretty hilarious.

It came out when I was 8 or 9, and I talked about how my mom had bought the album and how I had to listen to it all the time.

Rene’s friend, Francis, mumbled something.

“What did he say?” asked Zack.

“He said that we think about this song because it came out in 1994. So when people fled during the genocide, they would listen to this song while waiting for the news.”

Rubindi Umuganda

2009-11-08T10:01:00.000-08:00

Over the last two months, Mutuelle sensitizations have been scheduled and rescheduled a half dozen times. We made it through 4 of the 6 cells in Shingiro’s catchment area before the local elections. Many of the cell coordinators were not reelected (I don’t have any read on whether they did not run or were replaced by voters) and we had to wait for the new cell coordinators to settle in before we could approach them to let us speak to their communities.

At any rate, this past weekend we were able to speak with the good people of Rubindi. It was quite a Saturday morning.

The last Saturday morning of every month is Umuganda. Because taxes are hard to extract from low income communities, the government instead asks people to volunteer labor. It’s not a bad system, though ideally it would be unnecessary.

So at 9 AM on a Saturday morning, Elie, Consolate and I piled into the Land Cruiser, bright eyed and bushy tailed. We picked up Laurent, the Mutuelle Accountant and interim Manager, on the way.

Rubindi is in a really nice area, flatter than most of the rest of Shingiro’s catchment area, with lush, green fields during this, the rainy, season.

We rolled up the road into Rubindi and took the left fork to what I think of as its main town. When we arrived, Elie wandered off to find out where the Umuganda/sensitization was going to be while Consolate and I tried to interact with the community members. A woman sitting on a blanket was shucking ears of corn while about 12 children (probably not all her own) stood around her, a couple of them half-heartedly helping.

An old woman came up to me. She was smoking a pipe, and was leaning on a walking staff. “Matamuetze,” she said, and then all I heard was something about “Faranga.”

Elie came back, “It is in another place,” he said.

We left and the woman had to be restrained from trying to the Land Cruiser with her cane. “Awww,” said Consolate, “Some people just feel entitled to get money because they are old.”

We drove back to the fork in the road, and this time took the right fork. We drove a bit to what looked to be a school, where we found several people coming up from a path that led down into the valley below.

“They said that the Umuganda is across the valley, down at the new school that is being built,” said Elie, “You can ride with me while I drive around, or walk.”

I turned to Consolate, “Let’s walk.”

It was such a beautiful morning and within 15 seconds walking on the trail I know I had made the right choice.

The path was covered in fist-sized pebbles, neither small enough to crunch through or big enough to support our steps. So we slip-slided our way down the trail – even though I was wearing my hiking boots, I probably turned each ankle 2-3 times.

Consolate and I quickly lost sight of Laurent, who was moving speedily down the path. The view continued to be amazing.

There was a river at the base of the valley.

We crossed the stone bridge over the stream and arrived at the school where the Umuganda was taking place. There were several hundred people gathered in total, with community leaders talking to them in groups of 50-100 each.

“They are deciding who will be on the indigent list,” said Consolate. This is very important business, because indigents receive financial aid for Mutuelle, among perks. However, there is no really good ways to decide who is and is not an indigent – how do you compare wealth in a largely non-cash economy? Thus, a lot of people get on the list, many more than are given financial aid. We have found this to be a big problem for Mutuelle, because the final indigent lists are not announced until January or February – after the Mutuelle enrollment period closes. After the Mutuelle period closes (December 31), new enrollment activations are delayed by a month. The delay is to prevent people from waiting until they get sick to enroll. However, many people who are on the indigent list wait to see if they will get sponsored, and if they are not sponsored but want to enroll they then have to wait 30 days for coverage.

Elie had not yet arrived in the Land Cruiser. Consolate called him, “He says that the Land Cruiser is stuck in the mud,” she said. Laurent collected a group of 10-15 guys and they ran off to help push Elie out of the mud.

At previous Mutuelle sensitizations, we had attracted maybe 75-150 people. But because this was at an Umuganda, there were probably 300-400 people present. At this point, though, 400 sets of eyes fixed on my every movement doesn’t feel much different than 100.

As the minutes passed, I noticed small groups of people leaving. The Umuganda had concluded, so now people were just waiting to be lectured by us. I decided that I needed to do something to keep them interested in us and what we were going to say.
I turned to Consolate, “We have to dance.”

“What?” she asked.

“We have to do something really embarrassing, to make everyone think ‘what are those crazy Muzungus doing? I better stay to see if they do something interesting.’ C’mon, it’ll be fun.”

Consolate sort of giggled and refused to help.

So I did a little groove.

The idea, of course, worked perfectly. Every single person in attendance started looking at me and laughing and pointing. This was pretty fun for a couple of seconds.

Fortunately for my fragile dancing-ego, a few seconds later Elie pulled up with Gertie.

With no delay, the three to four hundred people circled around. Elie and Laurent spoke for a while - everyone seemed interested and listening but it’s hard to get a read on the crowd when you have no idea what’s being said.

After Elie and Laurent spoke, they opened the session up to questions. The head of COSA, the local quasi-governmental organization that technically runs the health center, got up and asked a question.

“What did he say?” I asked Consolate.

“He asked whether CCHIPs would help pay for extra indigents,” she replied.

I was struck by the extreme inappropriateness of the forum for the question. And it kind of pissed me off. I stewed – what kind of question is that? You can’t sand bag us like that in the middle of a presentation. Elie began to give an answer, though he appeared to be equivocating. I thought about the question, and what could be the right answer. I thought I had something worthwhile to say, and I went over to Elie and asked if I might say something. I began in English…

“I came to Rwanda two months ago from America. I have not been here long, but I’ve seen the beauty of this country and the potential of its people. Based on everything I’ve seen and the people I’ve meet, I can see that Rwanda is a great country. And I believe it will soon be a wealthy country. But this wealth will not be given to Rwanda. Received wealth cannot last. You must work hard to create it. CCHIPs is a tiny part of the growth and change that will come to Rwanda. Focusing on health centers, we are here to help Rwanda fulfill its great potential. I have seen progress made every day and I know that great things can be done. But we do not give hand outs. We can give ideas and training. With those ideas and that training, Rwanda can grow and support its own indigents. That’s what CCHIPs does because that’s the best use of our limited resources. We could cover everyone’s Mutuelle for a year, but it’s better for us to help Rwanda grow so that it can support itself forever.”

Elie said, in Kinyarwanda, “I’m sure you all understood what he said…” That got a good laugh from everyone. Then Elie began to translate what I had said…

…As Elie entered into his fifth minute of translating my thirty second speech, I turned to Consolate, “what is he saying?”

“You know Elie, he loves to go on and on. Right now he is saying how what you said is like how you treat a child. You support them less and less as they grow up.”
“Wait, what? No! That’s very colonialist. I did NOT say that.”

“It’s ok, they won’t care.”

But I care, I thought,OK, the analogy is not totally false, but it’s also not very PC. I kept thinking about it as Elie finished speaking. We thanked everyone for having us, and got back in the Land Cruiser.

As we drove out of Rubindi, we had to stop several times for people to move their mats covered in sorghum. It had become a sunny day and the people were taking the opportunity to dry out the harvest before selling it.

The whole ride home, I thought about what exactly I meant, about why CCHIPs is in Rwanda, about why I’m in Rwanda, about what forms international aid and NGO interventions should take. Not small topics, I guess.

At the very least, I concluded a few things, which I plan to touch more on in this blog:

1. In Rwanda, critical thinking and forward planning are missing skills sets. This is not to say that Rwandans are stupid or can’t make decisions, but there are socially constructed and learned ways of viewing the world that improve economic decision-making. These skills are far from ubiquitous.

2. I strongly believe that if those deficits in critical thinking and forward planning were erased, Rwanda would grow at a high rate for a long time.

3. For those with an entrepreneurial frame of mind, there are so many opportunities to make money here. Indeed, I’ve met several entrepreneurs here who I plan to write more about.

Snake in the Bed

2009-11-05T06:23:00.000-08:00

Rwandan men have a superstition that if their wife touches their penis, then they will become impotent when sleeping with other women. Jeanne D’Arc was speaking to a group of men about this and other sex-related topics:

“But you all sleep naked! Of course your wife could touch it when you sleep!”

They had, apparently, never considered this possibility. They were at once dumbfounded and terrified.

Kigali - Night

2009-11-02T06:51:00.002-08:00

We pulled up to “Hill Top Hotel and Country Club”. “They have golf? Tennis?” I asked Zack.

“No.”

After a tense discussion at reception regarding my failure to bring my passport from Musanze, we checked in and I promptly collapsed on my bed. The TV sat on a short table next to my bed, in line with my face. Zack turned it on and began watching soccer.

Perfect.

For the next 15 minutes I tried to sleep over the soccer announcer shouting in my ear.

There was a knock on the door.

“Time for drinks,” said Ro, from the hall.

Zack got up to leave, “I’ll be there in a bit,” I said, “I’m going to try to take a shower.”

I went into the bathroom. There was no shower, per se. The bathroom was maybe 25 square feet. There was a shower head, and a bucket on the floor next to the toilet. I turned the knob, and water shot out of the spout at waist level. I looked for some do-hicky that would redirect the water to come out of the shower head. No such luck. The shower head had a hose dangling down from its base, so I tried shoving this into the waist level spout. Nope.

After a hot day in Kigali, I felt grim. Sweat, oil and dirt was caked over my entirety. I have to do something, I thought.

I looked at the sink. Frowned. Shrugged.

I turned on the sink. I stepped into the bucket.

…

Feeling refreshed if slightly ashamed after my hobo shower, I wandered out to the patio, where Zack, Ro, and Jeanne D’Arc were interviewing a candidate for the Medical Systems Coordinator position.

While we waited for the interview to end, Amber, Elie and I chatted. I ordered a coffee and a beer – not exactly the wisest combination, but I wanted to simultaneously wake up and relax.

When the waitress came with my order, I was pretty happy to find that ordering a coffee means you get the whole pot. Also, my beer was a full liter. Excessive, but appreciated.

…

We had dinner at the hotel restaurant. Restaurants in Rwanda are generally unreliable – for most menu items, you could get almost anything based on your order. In Musanze, I routinely am brought the wrong thing, or nothing at all. The best defense to this problem is to order Briochete and chips. Briochete is goat kebob. Everyone in Rwanda knows what Briochete is and how to make it and basically all Briochete tastes the same.

Ro, Amber, Zack and I made the safe play and ordered Briochete and chips.
While we waited for the food to arrive, we talked about Rwandan culture. Women’s rights issues are for some reason a favorite a favorite topic of conversation for all the women present.

“In Rwanda,” Jeanne D’Arc said, “If a man is with a woman who is not his wife, that is called a ‘mistake’ and if there is a child it goes to live with its father. But if a woman does the same mistake, the husband divorces her and takes all the children.”

Jeanne D’Arc is part of a local group in Musanze. They beat wife beaters. Seriously. The Mayor's wife is a member of the group.

“Yeah, I think Gabby mentioned that women cannot whistle?” I offered.

“That’s true, only men may whistle in public,” said Elie.

After long time of good conversation, the food arrived. At this point I was too hungry to care, but I did notice that my fries were dripping with grease. To save money or because of lack of supplies, sometimes Rwandan restaurants don’t change the frying oil as often as they should.

As we sat and talked more after dinner, I noticed the grease begin to work its magic – I was suddenly deep in a food coma. Everyone was excited to be going out to Cadillac, and Amber secured the positive RSVPs of Elie and Jeanne D’Arc – Ro, of course, was in from the start.

…

After dinner, we went back to the room. I was ready to fall asleep. I lay down on my bed, and began drifting off to sleep. Happily. Softly. Nicely.

“Mike, it’s time to go to Cadillac.”

“Nooooo,” I protested.

And then we left for Cadillac.

…

We rolled up to Cadillac around 10:30PM. Zack and I had both voiced concerns that this was too early for a dance club, but the team seemed unfazed. Zack and I went up to the guy collecting covers – “500 each,” he said, eyeing us. Zack covered me and Amber. The bouncer seemed annoyed to get up off of his stool.

We passed through the leather, padded double doors. The doors opened into a large, dark room. Sparkling lights covered all the walls, a dance floor at the middle of the room. I looked around. Empty.

I almost ran to the bar.

“A Jameson and a red bull on the rocks.”

“Double up that Jameson?”

“Absolutely.”

…

After a bit, people began coming into the club. Most gawked at the knot of Muzungus dominating the bar next to the door, and congregated at the other bar across the room. A short guy came up to me. “Hello,” he said in very accented English, “How’s it going? I’m Leonard.”

“How’s it going, man?”

“You like Rwanda? You like girls?”

“Yes?”

“Look,” he said, pulling out his phone, “I know lots of girls.” He began scrolling through his contacts, showing me entries with names of girls…Mary, Anne, Jessica.

“Great man, I’m really proud of you,” I said, hoping he’d get the hint and leave me alone. I turned my head and saw Zack and Ro giggling at my predicament.

Apparently he was not appreciative of my tone: “So where were you in 1994?”

Woah, I thought. “Uhhh, I was 8? In America?” I offered.

“So do you like Edgar Allen Poe?” he asked.

“Who?”

“The poet.”

Thoroughly confused, and experiencing one of the most bizarre encounters in my life, I decided that I had had enough, “I dunno man, I’m going to go talk to my friends.”

…

We all chatted for a while. Then Elie, Amber and Jeanne D’Arc decided to do a bit of dancing. My stomach rumbled – between my unsettling conversation with Leonard and the greasy fries and goat, my mood and stomach were both frothing. Zack’s next move didn’t settle anything.

Zack waved me to the bar, where he waited with a small bottle of Waragi and two glasses.

Waragi is a Ugandan banana liquor. The name “Waragi” comes from the British colonists in Uganda, who called it “War Gin”. It is among the most horrendous drinks I’ve ever had the misfortune of drinking. It is technically vodka but it tastes like bathtub gin.

“Thanks for nothing,” I said, as I drank the shot.

…

As the night wore on, a couple groups of Muzungus came in.

I thought about the dynamics in the club – a lot of Rwandans having a good time, and a handful of Muzungus coming in and grabbing a lot of attention.

Why do we get so much attention? I wondered. We’re …rich?
I make over 100 times the average salary here, I realized. I could be a Sugar Daddy! Just like the billboard!

I processed the implications of this realization. In Musanze and at Shingiro, I’m exotic, different, a who-knows-what-to-expect entity. But in Kigali, there are enough Muzungus that we’ve established a collective reputation. Apparently it’s not a great one at Cadillac on a Friday night at 1 AM…

Rich, foreign, predatory.

Where was I in 1994?

Woah.

…

Several old Muzungu men began dancing with their Rwandan ‘girlfriends’. These guys looked to be in their mid-50s to late-60s. Old. There are a number of unsettling realizations that come from watching these couples. The most glaring, though, is what dorks the guys are.

There’s a serious cognitive dissonance when a supposed ‘millionaire-celebrity’ goofily performs a cringe-inducing ballroom dance to “Get Low”. Not ballroom dancing like he’s some pro. Ballroom dancing like the man’s never had the courage to try to dance. Like how the theatre kids 'express' themselves at a high school dance. Damnit, it was embarrassing. And enraging. My blood boiled.

…

Making the easy choice not to share a dance floor with Neil Strauss, Mystery, David D’Angelo and their ladies, I began to recognize just how bad my stomach felt.

Ro, Jeanne D’Arc, and Elie were ready to leave, and so was I.

We said goodbye to Zack and Amber, who decided to stay and dance, and we made a happy retreat to Hill-Top Hotel and Country Club.

…

Kigali is a beautiful city at night.

We drove home, and admired the lights of the city, an abrupt difference from Musanze, which is very dark at night.

“It looks like the lights of LA from a distance, but we’re so close,” said Ro.

She was right, though the lights, being so close, didn’t twinkle. The black wall of the hillside passed from left to right through the windows on the opposite side of the back of the Land Cruiser. Each light represented an open door or window of someone’s home. They gently slid past.

…

The next day, Zack, Amber and I sat in Bourbon while the others did more errands. We had a good time chatting and people watching.

The most memorable group of people I saw was a disastrously representative American family of four. They fumbled about, completely unaware of how loud their cultural hubris was shouting. Each member of the family was overweight. Each wore an ill-fitting t-shirt with a completely non sequitur print: a “Just Do It Later” Bahamas souvenir, a shirt extolling the virtues of Yellowstone national park, a Wal-Mart knock off of an Ed Hardy print, and a shirt bearing Taz, the Looney-Tunes character. The husband was stocky, with a protruding gut and a shaggy brown beard. His wife’s brown hair fell long and unkempt – she wore no make-up. One of the boys dragged the mother by her hand to the counter display of pastries. The boy pointed at his selection - not demandingly, not even expectantly. He showed no anticipation. That he would get whatever he wanted was a foregone conclusion. I witnessed the last member of the family, he looked to be about 6, eagerly snatch a cup of hot cocoa from his mother. He took a big gulp of the steaming liquid and a grimace broke out on his face. To his credit, he didn’t cry or scream. He just looked puzzled – what have I done to deserve this unpleasantness?

…

The drive home was really nice. It was late in the day, and the temperature was perfect. We had an English-language quorum in the back of Gertie between Zack, Amber, Ro and myself. During one of the shopping excursions, we had accidentally bought an Indian version of Trivial Pursuit. It was almost what we had wanted, and all we could do was laugh about how hard questions about cricket and Indira Gandhi would be to try to answer.

Dear Old Dartmouth Set a Watch

2009-10-23T08:26:00.000-07:00

LEST THE OLD TRADITIONS FAIL!

...

Around the world they keep for her,

Their old undying faith. 08!

Kigali - Afternoon

2009-10-21T10:08:00.000-07:00

Rene and I met up with the rest of the shopping team. The others had had more success than use, finding shower rods and curtains.

Gabby pointed out the place where he’d bought the power strips before. We crossed the street. Amber and I stood outside while Rene and Gabby went inside.

For a few minutes we waited and tried to talk to some children. Of course, they really only wanted “Agafaranga”, which means “give me money”. Around the Health Center, the children still wave and yell “Muzungu” at us, but they also yell “Muzungu Karuhu”, which means “European by skin only”, indicating that we will not give them money. These kids did not yet know that we weren’t tourists. “Oya,” I said in broken Kinyarwanda, “Yitqua muzungu karuhu.” (“No, my name is European by skin only.”

Amber turned to me, “I need to go meet my friend. I guess I’ll just take a moto-taxi.”

“Uh, there’s a couple over there,” I pointed across the street, distracted by the children and not expecting what came next.

“Ok, later,” she said. She walked across the street, into the crowd, and she was gone.

My jaw dropped. She’s just going to hop on a moto-taxi and be gone? Woah. Amber is setting up CCHIPs’ mental health program. She’s also lived in East Africa on and off for the last decade. So getting on the back of a moto-taxi in Kigali, saying “Serena Hotel” and hoping to make it there is no big thing to her.

Impressed but now alone with the street children eyeing me, I crossed the street. Elie knows basically everyone in Rwanda, and he stood with a handful of friends that he had run into. I climbed into Gertie and waited with Consolate.

A few minutes later Gabby and Rene returned with the extension cords.

“I only got two because I’m not sure of the quality,” Rene reported.

…

We rejoined Zack, Ro, and Jean D’Arc after their lunch meeting. They had another meeting scheduled for now o’clock at Global Fund.

…

For Team Mutuelle, Elie had scheduled a meeting at Gitega health center in Kigali. I put on The Strokes as we wound through Kigali. We only got lost twice on the way.

The Health Center was on a normal city block, with a screen fence and a covered open-air waiting area pushed up to the sidewalk. There were a number of people waiting to be seen, but Elie led us down a hallway and into the Mutuelle office.

We sat down with the Section Head and began to ask questions…

“What’s the population of the catchment area?”

About 35,000.

“What’s the Mutuelle enrollment %?”

We are actually over-enrolled, at about 120%, we have people coming to us from other catchment areas because we are very conveniently located.

“How much financial support do you receive for indigents?”

We receive support for about 15% of our population.

“How far of a walk is it for most people to the Health Center?”

Most people take moto-taxis. They are not expensive.

“What sensitization strategies do you use?”

We conduct a census of all the households of the catchment area. Because people live close together, it only takes the community health workers about week for each village (~500-1000 people). We also hand out flyers to inform people that they have to enroll.

“Wait, you are confident people can read the flyers? What is the literacy rate in the catchment area?”

The literacy rate is high enough that at least one person per household will be able to read.

“How prevalent are traditional healers?”

There are not too many of those in the City of Kigali.

I took in what the Mutuelle Section Head was telling us. So this is what it’s like to have all of the demographic variables line up in favor of actually getting people to use the health center. The Gitega health center is urban, has relatively high income, has a high literacy rate, has stronger cultural attitudes toward formal healthcare, and it is readily accessible via low-cost transportation.

I was frustrated. It’s so easy here! But, there is a reason we work at Shingiro and not Gitega. There is an extraordinary need at Shingiro, because of the demographic factors on the ground.

Still, the census idea had merit. And the meeting helped me think about the demographic challenges we face at Shingiro. And what we can do to address them.

…

When we returned to the Global Fund office, Zack, Jean D’Arc, Rene, and Ro were still in their meeting. We settled in to wait in Gertie out front. I threw on George Clinton’s Greatest Hits. Somehow I wasn’t finding “We Got the Funk”, so I settled into “Atomic Dog”.

Soon teenage street vendors came up to the car, apparently attracted by the music. Among the items I was offered were ladies shoes, a belt, and blue jeans.

…

The team came out of their meeting, and, after an excruciatingly long, hot day, we set off for the hotel.

When I Woke Up This Morning...

2009-10-18T06:15:00.000-07:00

Continuing re: Kigali trip tomorrow

Kigali - Morning

2009-10-14T08:32:00.000-07:00

My memory of the first visit to Kigali is a blur. Maybe it was the heat. Or the non-stop action. Or the sudden drop in altitude. Whatever it was, only the most jarring moments remain to my mind with any clarity.

…

I woke at 5:30 on Friday morning in Musanze. My buzzing cell phone alarm crashed into my dream – What? Why? Oya. I made some toast and coffee, and plopped myself in front of my laptop. After catching up on rugby news , sports, and current events for a while, I started to pack.

With Ro, our fearless leader and CEO of WWHPS-CCHPs, in the country there were a number of meetings to hold in Kigali. The plan was to go and meet all day Friday, stay overnight, and finish meetings and shopping on Saturday.

I didn’t pack much. Along with my laptop and a notebook, I threw a button down, clean boxers and socks, and a toothbrush into my bag.

By 7:30 we were all packed up and loaded into Gertie. The morning was cool and dark as we left Musanze but our excitement prevented any of us from trying to sleep on the way.

The trip began uneventfully. Like most rides in the Land Cruiser, the back section was dominated by Kinyarwanda speakers, so I zoned out to “Live at Folsom Prison”, which periodically skipped as we bumped down the pot-holed road to Kigali.

…

The day began to warm as we climbed along the ridge of the hills that precede the drop into Kigali. “Bob Marley, Greatest Reggae Hits Vol. 2” now played. Old Gertie, the team’s Land Cruiser, began to shake violently, not quite to the music. Thinking we had a flat, Zack pulled off onto the shoulder. The tire was fine.

We rumbled away again and Gertie shook harder. “It only shakes when we’re going uphill,” said Zack, “This is the last part right here.”

The road rose gradually but determinedly, up and up the great hill. We had climbed along the east side of the mountains for most of the trip, but now we crossed the ridge-back to the west side.

We reached a small town and stopped in front of a school. This time we all piled out.

The sun beamed down brightly on the white Land Cruiser, and I thought about what it might be like to get trapped at the top of the great hill. The thought did not animate a fear of danger so much as a fear of time wasted. Sitting on top of the hill, baking while our appointments in Kigali went unmet.

Ro thought the spark plugs might be dirty. Gabby popped the hood. Ro, Zack, Elie, Rene, Gabby and I crowded around the engine. Though I know nothing about cars, there’s something deep within most men that drags us to the exposed engine of any car. I can nod, grunt, and shake my head with the best of them. The actual mechanics and engineers of the group – Elie, Rene, and Gabby – conferred, but concluded there was nothing they could do.

We piled back in and Gertie started up again, shaking but moving on.

…

Rwanda is remarkably densely populated. It holds 10 million people packed into an area smaller than Massachusetts. Moreover, the biggest and arguably only city, Kigali, has only 800,000 inhabitants. The rest of the country is covered in small farms. As we descended into Kigali, the demarcation of city and countryside never came. The city limits overlap with the countryside such that billboards and corner stores seem to rise up out of the fields of banana and maize.

…

Kigali is at once bustling, chaotic but also small. It holds so much activity is pressed into a tiny space. Wherever you are, you feel trapped on the side of a hill, slowed by the incline, the heat, and the crush of just under a million people. Most people live in homes ranging from modern condos to mud-brick constructions, though like any city Kigali has its fair share of the homeless and beggars. But in Kigali more of the beggars than I’ve ever seen have missing or deformed limbs. The limbs are clearly not deformed, but damaged – a beaten wrist or an ankle forced back upon itself. The wound is healed, but not healthy. The beggar is always functional enough – smiling sometimes even. But often they move with great strain. The injury is not genetic, but for those carrying the wound the original form will not be recovered.

…

We stopped first at the Millenium Village Project offices, where Zack and I got out. Affiliated with Columbia, it also houses staff members from Columbia’s Access Project. We work closely with Access in Musanze. We met with Teddy about our proposed filing system for Shingiro.

Currently, the health centers do not maintain comprehensive patient histories. This leads to misdiagnoses and other problems stemming from a lack of communication. For example, patients are sometimes treated the same way for the same disease multiple times. At one community meeting in Mugali, a woman explained that her son was not treated for intestinal parasites because the pharmacy was out of the drugs prescribed for him. When she returned after the drug had been restocked, the health center did not have a way to verify the boy needed the drug, so he had to be retested. A filing system would cut down on such wastes of patient time and health center resources.

Teddy gave us a number of helpful suggestions and we had a good time with the reclining pleather desk chairs and the air-conditioning. I snapped off a picture of a map on the wall, finally wrapping my head around Musanze District geography:

...

Zack and I hoofed it up a hill to meet the rest of team at Bourbon Café. We climbed up the hill and into the office tower, probably 6 stories tall. Bourbon Café sits in the office tower’s indoor atrium. This courtyard mall serves as a kind of Muzungu haven in Kigali. There is one grocery store and a few small shops. Bourbon sits in the back-left corner of the atrium.

Jean D'arc and Consolate at Bourbon Cafe.

The walk up the hill in 85 degree heat left both Zack and I sweaty messes. Zack suggested I order the “Moca-Mania-Cowa-Chino”. When the waitress brought it out, I was confronted with a chocolate-coffee smoothie topped with whipped cream. It was the most impressive artifact of American cultural transfer I’ve yet seen Rwanda. It’s the kind of very American drink my brother always orders at Starbucks or Dunkies – over the top, with so much sugar that if you put your straw on the bottom of the glass you end up chewing on grains of sugar crystals. At 3,500 francs (~$7), it did not disappoint.

...

Zack, Jean D’arc, and Ro had a lunch meeting with Josh Ruksin, a Columbia professor and the head of Access.

While they went off to their lunch, Elie, Gabby, Rene, Amber, Consolate, and I went to ours. On the way to Africa Bite (pronounced ‘bee-tay’), Elie pointed to a collection of short buildings at the point between the hill we were going down and the hill we were about to climb up, “There is Cadillac, the nightclub.”

“What is it like? They dance there?” I asked naïvely.

“Oh yes. Hehe, the last time I was there was in 1988. A lot of dancing.”

Zack, Rene, and I had talked about the possibility that we would go to a nightclub while in Kigali. Cadillac was on the list that Rene provided, along with Planet, B-Club, Black and White. Rene had gone through them:

“Cadillac is popular, a lot people. Planet is good also – those are the two more popular clubs. B-Club is VIP. You have to dress to impress. It’s expensive, if you go in jeans you don’t go in. So it’s less popular. And there is Black and White. It’s OK, it used to be more popular a few years ago.”

Africa Bite turned out to be a pleasant little restaurant. We piled our plates with a buffet of African dishes: curried lamb; igasafria, a hot pot of bananas, potatoes and tomatoes; ugali, maize or cassava flour mixed with hot water into little balls; sweet potatoes; mashed bananas; rice and beans; and a naan-like bread. There were also two sauces, a tangy yogurt sauce and pili-pili. Pili-pili is a mashed chili paste, hotter than almost anything else I’ve been able to eat, including my beloved Sriracha.

We ate in the restaurant’s garden, enjoying the breeze.

...

After lunch, we passed Cadillac once more on the way to shopping. Across the street, I noticed a strange billboard – a man beckoned to two young women, one of whom drew away while her friend pushed her toward the man.

“What does that say?” I asked Rene and Consolate.

“It says to not have a sugar daddy,” offered Rene.

“A sugar daddy?” I asked, “It’s an advertisement against prostitution?”
“Sort of, basically,” said Consolate.

“No, not prostitution,” said Rene, “young people here are very poor, so sometimes the young women will go around with much older guys and let them buy them things.”

I thought on it: “Same as it ever was.”

…

We drove to what seemed to be the commercial center of Kigali. The streets are narrow and feel more so because they are packed with people – moving, hawking, being. Everywhere there are children and beggars, teenagers selling blue jeans, belts, and high-heeled shoes. Internationals stood out in the mostly-Rwandan crowd: stocky Germans wearing wire-framed glasses, short sleeved button down shirts, and crew cuts; spiky haired Chinese dressed in baggy jean shorts and t-shirts with cut off sleeves, and of course, the gawking, pointing, squinting American tourists.

Given my lack of local savvy, inability to speak Kinyarwanda, and skin color that screams ‘SUCKER’, I was more a liability than a help in the effort to purchase supplies. Determined to look more Jason Bourne than Clark Griswold, I threw on my ‘informed-American’ swagger and followed Rene into an electronics store. Every inch of the store was covered in electronics for sale. The aisles were filled with merchandise, small washing machines jammed alongside coffee makers and vacuum cleaners. Along the back wall was a long counter and above it light switches and bulbs.

A Chinese customer stood in front of the counter. He was negotiating with the clerk in Kinyarwanda. Say what you will about their efforts to establish an economic sphere of influence in Africa, at least the Chinese really dig in. Along with a scattering of Indians, the Chinese are the only non-Africans that I’ve encountered that speak Kinyarwanda. The power adapter/strip combo Rene was looking at was no good – “they say it will be 12,000 but we got these for 8,000 a few weeks ago, let’s try another place.”

The next store we entered was not an electronics store. It had a main aisle running through the middle of the store, with perpendicular rows of shelves that nearly reached the ceiling. Each row was maybe 3-4 feet across. The store was not well lit. Rene ask the attendant where they kept the power strips. He led us to the end of the main aisle, and down the left half of the second to last row. The power strips were at the end of the shelf. Rene decided that this power strip was not right either as another group of shoppers entered the row.

There is no word for “please” or “excuse me” in Kinyarwanda. I’ve always thought of pleasantries as a bit disingenuous, but in their absence I’ve come to realize how essential they are to American culture. It is jarring when an English-speaking Rwandan forgets to culturally translate his or her thoughts. I’ve been on the receiving end of comments like “You will do the analysis for me,” instead of “you are so good at the analysis, and I don’t know how to do it, would you mind doing it for me?” Or “Give me the internet card,” instead of “can I use the internet card when you are finished using it?”

The convention also applies to crowds. Rwandans literally push each other and place hands on each other to get where they want to go. As I led Rene and the attendant out of the row, I was confronted with a cultural translation problem. The people that had moved into the row took up the whole of the 4 feet across. In the US, people move out of each other’s ways in such situations, almost unconsciously and rarely with acknowledgement. Here there was no indication that the Rwandans noticed me or planned to get out of my way. Unable to bring myself to dragging the other shoppers out of my way, I sort of shimmied around the group. I squeezed myself against the shelf and used my back and butt to carve space for the rest of me to birth my way out of the row.

In the light of day outside the shop I gulped the fresh air. “One more place to try,” said Rene. We crossed the street. This time, I tried waiting outside, hoping not to earn us the Muzungu price. Rene came out, shaking his head, “She wants 10,000 – that still seems high.”

...

To be continued…

Another picture

2009-10-13T09:09:00.000-07:00

But it's a good one.

Happy Friday

2009-10-09T05:49:00.000-07:00

The Economics of Squishing

2009-10-04T02:34:00.001-07:00

On Tuesday morning we woke up early and headed to Shingiro. We attend the Shingiro staff meeting on Tuesdays, which starts at 7:30. After waking up at 7, I coughed down a breakfast of banana bread and a cup of coffee. Outside Elie, Amber, and Shingiro nurses Pascaline, Louisa, and Mary wait in the Land Cruiser. Ro sat up front. Zack got in to drive, and Consolate got in the back with us.

As we left the project house, there were seven of us in the back seat. This did not bode well for my comfort. Already I was confined to a small area of personal space and I knew that we would be picking up Jean D’Arc and Rene on the way. This would push me over the edge from ‘morning cranky’ to ‘full-blown-squashed-and-resentful’.

We picked up Jean D’Arc and then Rene. “Rene should sit up front with me” said Ro, “because, Elie – aren’t we picking up two more people?”

“Hehehe, maybe two, I think three though,” chortled Elie. This would push the number of us in back seat to 10 or 11.

I began to think about the economics of the squishing decision. Given a scarce resource – a ride to Shingiro – there should be some logic behind how it is distributed to the pool of potential users.

Scenario 1: Perfect World

Assumptions:

Riders have homogeneous preferences between cost and comfort
Riders are added until the trade-off between cost and comfort are equal (due to homogeneous preferences, this could be either for each person or total utility)
Once in the Land Cruiser, an individual cannot get out (once the decision is made to get in, social norms mean you can’t get out, but your original preferences stay intact)

Implications:

The alternatives to piling into the CCHIPs’ Land Cruiser are 1. taking a moto-taxi or 2. walking. A moto-taxi costs RWF 200. For simplicity, I will assume the cost of walking is equal to taking a moto-taxi, RWF 200.

As more riders enter the Land Cruiser, personal space is not impeded until there are 6 people in the back. At this point, the squishing and squeezing begins. Once 10 people are in the back of the Land Cruiser, all personal space is gone, the back is full, and on average most people would say that additional riders make the alternative – paying for a moto-taxi – a better option.

Thus, potential riders should stop wanting to get into the CCHIPs van at the same time that each of the current riders would prefer no one else get in – once there are already 10 people in the Land Cruiser. Lovely. Unfortunately, that’s not the way the story goes. Real world preferences are not homogenous. In this case, being a pampered American, I was far less willing than everyone else to squeeze.

We arrived at the turn-off of the main road for the bumpy, dirt road to Shingiro. Two more Shingiro nurses piled in. At this point we had 10 in the back of the Land Cruiser. Though everyone else seemed ok, I was definitely not happy.

Scenario 2: Social Utility Maximization under Heterogeneous Preferences

Assumptions:

Riders have heterogeneous preferences between cost and comfort
Riders are added until the marginal social benefit of an additional rider is negative (group utility is maximized)
Once in the Land Cruiser, an individual cannot get out

Implications:

In this scenario, my preferences are crankier than the group’s. My frustration builds much faster than everyone else. In fact, at 8 people I’m already indifferent to the unpleasantness of riding in the crowded Land Cruiser vs paying for a Moto-taxi. For me, each additional person adds a growing amount of pain and discomfort, which I translate into an increasing willingness to pay for the alternative. Conversely, the group only adds a set amount of pain for each person added.

The group seemed content with 10 people in the Land Cruiser, so I was willing to stay quiet. I’m a guest here, a volunteer. Because one of the assumptions is that I can’t get out, I was locked into my original, correct decision to ride the Land Cruiser.

However, as we cruised up the bumpy, rocky road to Shingiro, Zack stopped not once, not twice, but three more times to pick up more riders. This wasn’t just unpleasant for me – everyone seemed sort of cranky when we arrived.

Scenario 3: Personal Utility Maximization under Heterogeneous Preferences

Assumptions:

Riders have heterogeneous preferences between cost and comfort
Riders are added until the personal utility of an additional rider is negative
Once in the Land Cruiser, an individual cannot get out

Implications:

Here, even though everyone already riding in the back of the Land Cruiser is done adding people, the driver and potential additional riders hold the power to make the decision.

Because the additional riders (the "squishers") have a different preferences than the group – they are more willing to sacrifice on comfort – the utility of the group is not maximized (i.e. – on the whole the group is annoyed).

In fact, at 13 riders, the group average cost of riding (in discomfort) is RWF 350 vs the alternative RWF 200 for the moto taxi. Thus, the total loss is:

(RWF 350 - RWF 200) x 13 = RWF 1950

The driver, who also holds the power to make the decision, is not faced with the choice. He knows he can bank on the gratitude of the additional riders he picks up. Good manners and fairness mean that the resentment of the group will be muted or unexpressed. Unless one of them has a blog and a long memory.

Scenario 4: Reality

In reality, the Rwandans are pretty happy jamming as many people into a vehicle as possible. Without me, the “group preference” line above wouldn't cross the Moto-taxi line at RWF 200 until 14 or 16 people are in the back of the Land Cruiser.

In fact, at 13 people, my personal discomfort cost RWF 2100 (discomfort) - RWF 200 (alternative) = RWF 1900. That means that the other people, on average, only were about RWF 5 uncomfortable.

Sadly, while I was close to establishing that Zack is a jerk through economics, all I really proved is that I need to suck it up.

But, as this video proves, it was a little crazy.

Friday Night No-Lights

2009-10-02T08:56:00.003-07:00

After my first week, I was ready for a break. I had been introduced to the health center, to the nurses, and began to get a sense of the work that I would be doing. Even so, there was little I could actually accomplish besides reading old government reports and messing around in Excel. When Friday afternoon rolled around, I was pleased as punch.

Government policy mandates that all organizations, including NGOs, must allocate office time to “sport”. Friday afternoon is when our team participates in sport. On my first Friday, we played soccer with the staff from Ruhengeri Hospital.

I threw on my new Warrior Kung Fu’s (for a light touch), a Dartmouth rugby t-shirt, green mesh shorts, and high socks.
“You look like a moron” said Zack, as we arrived at the field.
“True,” I obliged, “but I’m a celebrity here – I say what’s cool.”
“Keep telling yourself that…”

The soccer field lies near the center of Musanze - it’s more a stadium than a field. The complex is surrounded by roads on all sides, which makes it feel almost urban. The complex contains a full sized soccer field, a track running around it, and stands on one side. On the other side of the field is a large open, grassy space, presumably for practicing, and a small basketball court, at the end of, set back from, and perpendicular to the soccer field.

As we walked down into the stadium, I looked around. Two teams faced off in a scrimmage on the field, with about 20 spectators along the near sideline, away from the stands. Another thirty people kicked around soccer balls on the open field and others milled about. In total, the complex felt full, but not crowded. The rest of the CCHIPs staff waved to the group on the basketball court, the Ruhengeri Hospital staff.

The hospital staff looked to be mostly in their late 20s and 30s, all male, with varying degrees of athleticism. I stepped onto the court, shaking hands and exchanging “we-don’t-speak-the-same-language" smiles. I was pumped to go, though on the basketball court were about 20 people.

The overcrowding was resolved by making three teams. My team was the first to sit – figures. While we waited, one of the Ruhengeri Hospital staff led us in drills. Are you kidding me? I thought. Here we had the CCHIPs staff, all of us more or less adults between 23 and 45, kicking a soccer ball back and forth and running laps. It was surreal, like a middle school gym class.

After a short wait, we were on. It was me, Consolate, Monique, and our coach, who I nicknamed Earnest, versus Zack, Jean D’Arc, Gabby, and Rene.

Long ago, when I was 8, I played in my first ‘travel soccer’ game. Back then we played six against six and the fields were small – speed wasn’t a factor, just a light touch and a good sense of direction. I was very good. As time went on, the field got bigger, speed mattered, and my skill set slipped out of relevance for competitive soccer. Fair enough – eventually rugby became a more than adequate substitute.

But on the basketball court, four on four, I was back in my element. I dribbled around Jean D’arc, around Gabby, and passed off to Earnest. No problem – light, easy, fun.

The game continued, back and forth, with no one scoring for five minutes. It was time to shuffle the teams again. Those that didn’t really want to play, like Jean D’Arc, turned in for good at this point, and two permanent teams coalesced.

As we began to play, the game picked up tempo and ferocity.

The goals were the base of the basketball hoops. The hoops sit on a box frame, with two poles lined up with the court. The goal was small, but so was the court. I took a shot and the ball sailed between the posts. “No goal,” said Rene. What!? “You have to hit the post, not shoot through them.”

It actually made sense, given the size of the field and lack of goalies, but I had to ask, “Why haven’t I been told this yet?”

Over the next 10 minutes, as my team continued to put pressure on the other while they tried to bring the ball out of their end, I shot the ball through the posts two or three times. Damnit, I guess I just need to keep shooting, I’ll get the hang of it.

As my frustration grew, the momentum also shifted. Despite Consolate’s heroic efforts, Zack’s team effectively exploited our “guys on offense, girls on defense” strategy. They pinged two quick goals.

I quickly realized something key – on such a tiny field with unorganized teams, we’re not playing soccer, we’re playing basketball with our feet. Soccer is all about setting up the perfect shot. You hold the ball and move it slowly down the field. Territory matters because the field is large. Possession is important because the opposition can quickly kick the ball away from shooting range. But on a basketball court, shooting at poles, the key was just to rip off as many shots as possible. You could set up shots quickly, and every shot was low probability, including the ‘perfect shot’.

With that thought in mind, I began to push the ball down the court every chance I got.

Finally I scored my first goal. “Mmmmm, that tastes goooood!” I yelled at Zack as I ran by, “I’m gonna get me some more of that.”

After a few more minutes, some of the guys from Ruhengeri Hospital had had enough, and I invited a couple of the local kids to step on. They were probably 14 or 15, but built like soccer players and wearing cleats. Though the cleats made them slip around a bit, they were quick and talented additions to the team.

Quickly we began to lay it on, scoring a couple goals. The kids on the sideline laughed whenever I would compliment one of my local additions on a nice play.

Zack grew more and more frustrated as members of his team disappeared. By the end of the game it was 7 on 3, and – among other feats of bravery, strength, and skill – I had scored a header from midcourt (mostly due to the lack of numbers on the opposition).

Finally, it was too dark to go on and we called it a night. My shirt was wet with perspiration, my brain flush with exercise- and winning-induced endorphins. I shook hands with everyone whole-heartedly.

I looked around the stadium in the twilight. I was happy and felt accomplished. Though the air was thin in the altitude and my body weak from nearly two weeks since seeing the inside of a gym, I had a great time and impressed the locals with my Muzungu talent.

Sport is great – in a two hour period I rode a narrative arc that I will hopefully replicate in my work and life over four months. (Though I expect my competitors will be malnutrition, poor access to healthcare, and poverty instead of friends and colleagues.)

My Umbrella

2009-09-29T10:31:00.000-07:00

Another gem from Jean D’Arc, who has terrific stories about rural Rwandan culture and superstitions. She is somewhat unusual for Rwandan woman – she talks about sex. As a nurse, I suppose it comes with the territory.

As part of her job, Jean D’arc advises couples on family planning, including condom use. Sometimes she demonstrates how to unroll a condom (think the banana in health class).

One day, a man she had counseled came to her, confused and upset:

“Jean D’Arc,” he said, “I followed your instructions exactly for using the condom, but my wife still got pregnant!”

“Tell me what happened,” she asked.

“I did it just like you showed me. Before I made love to my wife, I put the condom on my umbrella.”

Mutuelle

2009-09-24T09:37:00.003-07:00

Shortly after I arrived, Elie and Consolate brought me up-to-speed on their efforts on Mutuelle (community insurance). It’s one of my big projects here and it consists of three goals:

Boost Mutuelle enrollment in the Shingiro catchment area for 2010
Develop a report for the District Mayor on common barriers to enrollment and recommendations to overcome those barriers.
Liaise with the Shingiro Mutuelle office as part of the broader effort to make Shingiro a better health center

Mutuelle enrollment costs RWF 1,000 per household member for each year. The Mutuelle-subscription year corresponds to the calendar year. To prevent people from only purchasing Mutuelle when they become sick, aka to prevent adverse selection, Mutuelle must be purchased before the year begins. If families wait until the subscription year to purchase Mutuelle, they face a 30-day waiting period before their Mutuelle enrollment becomes active and can only purchase for the current year until June. Mutuelle enrollment for the next year begins in August. Thus, from now until the end of December is the important period for enrolling community members. An additional measure against adverse selection, heads of household must purchase Mutuelle for every member of their households, not just those that are mostly likely to become sick.

Mutuelle enrollment is the key to creating access to the formal health system in Rwanda. Indeed, looking at the data from 2008 in the Musanze district, there is a strong correlation between Mutuelle enrollment and health center use at the 11 health centers:

*I should note, in loyalty, fairness, and kudos to CCHIPS, that “Mutuelle Enrollment vs. Target” and “New Cases Seen vs. Target” in Shingiro are both up considerably in 2009 - no doubt helped by CCHIPS involvement.

While correlation does not prove causality there are a few points of reality that make the distinction moot:

Mutuelle is a great deal for its members. The true cost of health care is far higher than the RWF 1,000 enrollment fee, which is ‘only’ about $2. Mutuelle is subsidized by various NGOs and the government. Thus, beyond the normal insurance functions of consumption smoothing, risk pooling and so on, Mutuelle gives preferential access to the health center vs out of pocket payers.
We do see enrollment creep up between January and June, as people recognize that they need Mutuelle after they get sick. However, this just reinforces the argument for educating people about the cost-savings of using Mutuelle before they get sick. Mutuelle creates access to health centers at an affordable price.
The subsidization means that adverse selection is less of a problem, in the short run at least. Very few families have a risk profile for illness that makes not purchasing Mutuelle a good bet.

Therefore, I suspect that the Mutuelle enrollment rate indicates the proportion of the population that a. believes in the formal healthcare system vs traditional healers or doing nothing at all and b. is able to pay for coverage.

Focusing on Mutuelle enrollment allows the health center to ‘bag’ wins and concentrate its ‘sales’ effort within a relatively small window of time. We don’t have to expend significant resources all year round trying to one-off convince people on the benefits of using the health center. We know how many people will use the health center based on our enrollment figure, and we know the time period that we need to focus on to sell health center use for the whole next year.

A question raised by the subsidization of Mutuelle is: ‘if you are already heavily subsidizing the system, why not just give free healthcare to everyone? Why make people pay anything at all, if that will get them to use health services more often?’

There are a few reasons:

The poorest (“indigents” in local parlance) receive financial aid to cover the Mutuelle enrollment fee (though we are looking at the current system of identifying these people – it does not work very well).
Forcing people to pay for at least part of the cost of care helps prevent adverse incentives from forming (such as creating a sense of entitlement, etc). It might also create good habits and general acceptance of health insurance as ‘just something you do’.
NGO pockets are deep, but not limitless. In fact, we are currently doing analyses of what would happen to the Shingiro budget if various sources of income were delayed or ceased (my working hypothesis: if Mutuelle cut back on its reimbursements, the health centers would quickly become insolvent).
Most important is the recognition that the current system is developing alongside the Rwandan economy. The goal is for most parts of the healthcare system to not fundamentally change when the system becomes self-sustaining. It is important to sensitize (a favorite word of Rwandan technocrats) the population to the benefits of using the health centers, even if they cannot afford them currently. Indeed, using the health centers now might help people be able to afford them in the future. The hope is for the development of a virtuous cycle with better health standards driving income growth driving a greater ability and willingness to pay for health services.

Despite these qualifications, it is clear that Mutuelle is not an ideal system for paying for care. However, it’s hard to imagine an ideal system, given the willingness to pay for most people is lower than the cost of providing healthcare. But we’re not here to create an ideal system. We are working at a local level; we are not trying to redesign the Rwandan healthcare system or how the government should ask its citizens to pay for that system. We are trying to help the health center staff maximize the quality and usage of the health center in a way that is implementable, replicable, and can be easily monitored. Mutuelle is clearly important to this effort.

Nyarabuye and Development Economics

2009-09-23T22:10:00.000-07:00

This post is a first of a handful oriented towards development economics that I hope to publish over the next few months. There is a world of difference between the theories in the Ivory and Ivy Towers and the world around me. Whereas academics are clean, the world is messy. But both are interesting…

We had a much stronger turnout for the Mutuelle meeting at Narabuye than at Mudende. We did our schpiel, and then Elie translated for me as a local official explained several government policies.

Two policies in particular piqued my interest...

Umudugudu

Under the Umudugdu (Village) policy, rural citizens will be given a 20m by 25m plot of land within a village to construct a house. These villagers will relocate from their homes which are scattered across the countryside.

A lonely house far from neighbors.

Homes in the fields.

Currently, these villagers live near their fields, but clumping will (hopefully) allow human and health services to be more easily delivered. These services include:

· Rural electrification

· Sanitation and indoor plumbing

· Communications infrastructure

· Local trade and commerce

· Closer access to health facilities

By moving closer together, individuals lower the marginal cost of all of these services/transactions. Additionally, to mitigate the switching costs, the government is giving advanced warning, including recommending that people do not invest in permanent homes until the villages are laid out. This policy has not yet been enacted and surveyors continue to plot the ideal locations for villages and homesteads within villages.

Though on the whole I think it is a sound idea , there are a handful of potential drawbacks to the policy:

This policy will increase the monitoring costs for residents. Currently, it is easy to make sure no one steals your crops – you look outside. Now people will have to monitor their crops in some other way. Perhaps it will give rise to security services – this could be an important value add for a crop insurance program.
It is unclear who will bear the switching/moving costs
People here are really poor. If they have a good thing going where they live now, it sucks to force them to move.

Crop Specialization

The speaker next spoke about a crop policy the government is enacting. Going forward, people will only be allowed to grow particular types of crops in different regions. For example, some regions may grow maize while others potatoes and others wheat. The speaker told the people that at some point the government would be inspecting fields and tearing out plants that are not allowed to be grown in the region.

This drew a loud outburst from the assembled villagers. They did not seem to love this policy. My initial reaction was first-world, freedom-loving indignation. People should be able to grow whatever they want! But then I thought about it a bit:

Positives:

1. Encourages specialization

a. Hopefully, farmers will more efficiently grow one or two crops instead of 5 or 6.

b. This specialization should generate a net surplus of food, which will encourage trade and employment opportunities outside of farming

2. Encourages trade

a. People will sell the one type of surplus crops that they grow for cash and purchase a basket of other types of crops and goods and services.

3. Encourages the use of currency

a. Currently, one of the issues we face with Mutuelle (community health insurance) is that people use bartering instead of cash, and therefore have no way to pay for enrollment.

b. Trade will necessitate the use of money

Negatives

1. Ignores individual preferences / abilities

a. Hopefully government agronomists designated districts best suited for growing maize as maize districts and so on

b. Even so, there will be certain farmers that are currently better at growing some crops over others and areas of land within regions that are better suited for different types of crops than is designated based on region-wide characteristics. This will lead to sub-optimal use of land. (Though that is not to say that the land is currently being used more optimally.)

2. Will interfere with market function

a. Related to the first point, in a perfect system, market demand, field characteristics, and farmer abilities would determine the most profitable crops to grow in a particular field.

3. Several residents noted that they do not currently grow the crops designated for their region. Thus, they faced switching costs such as 1) learning how to grow the new crops and 2) buying the initial inputs such as seeds or crop-specific tools

4. Our nutrition program emphasizes, among other things, a balanced diet. While in theory it is great for farmers to specialize and trade, the policy might encourage “diet specialization”.

5. Crop diversification may help hedge risk. Farmers might plant different crops that are resistant to different disasters, like drought-resistance crops, pest resistant crops, etc. With specialization, a whole region can be wiped out by a particular crop disaster (think Ireland in 1848).

The policy will not be enforced for some time period, so people will have time to adjust. At its core, the crop policy assumes that the government will make better choices than local farmers. Given the low penetration of education among the rural poor, I’m not convinced that this is untrue.

Generally, it seems hard to know whether it makes sense to wait for an endogenous impetus to push such a large change or use the force of law to induce an exogenous shock. There will likely be a number of unforeseen consequences of both these policies, but the long term benefit may outweigh the short to medium term pain.

Over a long time horizon, the hope is that these policies together will encourage better access to human services, economic specialization, the development of a rural service sector, and, generally, economic development. These policies take a step in the right direction. However, in the short run the policies are likely to 1. provoke widespread non-compliance from the population and 2. create unintended and unforeseen complications for everyone involved. The successful implementation of these policies will depend on the government’s flexibility in reacting to these issues and strong monitoring and enforcement mechanisms.

I’ll keep watching, talking, and listening to people.

Adjusting to a New Reality

2009-09-16T12:41:00.000-07:00

Sometimes you have to take the slow boat to China, or Mudende. Patience is not really part of a 23 year old’s repertoire of emotional or mental paces. Slothfulness, sometimes, but patience not so much. A recent Mutuelle outreach trip to Mudende tempered my ambitions and fantasies somewhat, but also gave me hope for the long term potential of CCHIPS and Rwanda.

On a beautiful Tuesday morning, we hoped to lead a Mutuelle (community health insurance) information session at Mudende. We drove the 20 minutes to Shingiro, picked up representatives of Mutuelle and several Shingiro nurses.

As we were about to leave Shingiro, I realized that the two pots of coffee and two liters of water I had consumed earlier would be catching up to me at some point during the course of the morning. Thinking nothing of making assumptions like: “oh, they’ll have a toilet at Mudende” I decided to wait.

We then drove the half hour up the winding, rocky, bumpy road to Mudende. The road is narrow and at times seems to shoot straight up the side of the hills. Elie remarked that the road was newly resurfaced, which is good because it’s hard to imagine driving on a less passable road.

I sat up front with Elie, and asked him about the people and plants as we drove. We passed fields of beans, potatoes, gooseberry, maize, eucalyptus, and bamboo. Elie explained that the altitude prevents the cultivation of coffee and that avocados grown here are much smaller than those grown in the south. The sun was bright and I waved to the constant stream of children who would run to the side of the road as the Land Cruiser rumbled by. It was a nice drive except for all the bumps in the road (and we’re talking softball to volleyball sized rocks here).

Mudende sits on what seems to be a peninsular hill jutting out into the openness of the falling hillside. As we made the final turn down the hill peninsula, we came upon a young shepherd and his flock of about a half dozen sheep. The shepherd stood on one side of the hill and his sheep on the other and as we drove past the sheep got out in front of the truck. They began running away from the Land Cruiser and down the path and we nearly herded them to Mudende. It was only a quarter mile and the shepherd ran behind us, yelling at us, the sheep, or whoever would listen. The sheep finally turned up into a field just before we entered Mudende.

As we arrived, I was in for my first “Muzungu Celebrity Experience”. Literally dozens of children began shouting “Muzungu! Muraho Muzungu!” and variations on that theme as they began chasing the Land Cruiser. We pulled up next to the community offices and we all got out. I didn’t know quite what to do, so I smiled and waved to the children. Soon, a police officer chased them away in a hilarious flock of giggles and yelling.

As is common in Rwanda, and I would guess most places with poor roads, communication, and little automobile ownership, everyone was late. We settled in to wait for the community to arrive so that we could begin our presentation. Unfortunately, as the only Muzungu in the group, this meant a lot of standing around and laughing along at jokes that I didn’t understand.

After a few minutes, I asked Rene if he could ask someone where a toilet was. He came back a minute later reporting that the nearest toilet was at the school we passed on our way in. The school was only a quarter mile away, but it also lay in the treacherous territory of the Lollipop Guild. I didn’t need 100 Rwandan school children watching me pee – talk about stage fright.

We waited some more as Elie went to find out why there were no locals present for the meeting.

I took this opportunity to take in the view. The town overlooks a large valley, stretching out into the haze. Rwanda is a beautiful country, all green and brown. And yet the beauty of the landscape clashes forcefully with the poverty of its rural population. From a distance, the tin roofed huts and the smoke rising from cooking fires and slash-and-burn agriculture present a beautiful image. Rustic. For an American, it stirs within the myths of our American frontier. But when you approach one of the tin-roofed hut s and you are greeted by a small child with the big belly that signifies not over-indulgence but such malnurouishment that his body is too weak to keep his organs tight below his chest cavity, well, the myths disappear. Reality sinks in. The need is immediate, but the obstacles are many and, at times, desperately frustrating.

Elie returned and reported that no one had canvassed to spread the word about the meeting. We would need to reschedule. However, before we could reschedule we needed to wait for another member of the Mutuelle team to arrive.

I squirmed as we waited some more. Elie is a gregarious guy, so he kept everyone entertained. All the Kinyarwanda speakers anyway.

I began to circle the cell office. I noticed, excitedly, that on the back of the building seemed to be several latrines. I tried each door down the line. Locked. Locked. Locked.

I returned to the group talking and asked Rene about a toilet. He pointed to a man coming out of a small group of trees. “You can probably do that.” I considered it, but Rwanda is very densly populated, especially around the cell office. No, best not be the foreigner that comes in and pees on the country.

I returned to the group again, and noted that there was not a large group of residents waiting, but there were 15-20 elderly people waiting. I asked Elie about them. He said that they were not here for our Mutuelle presentation, and wanted to meet with cell officials to discuss other matters. Fair enough, I thought, but they look bored, we were certainly bored, why not talk to each other about Mutuelle anyway? I asked Elie. Politics. We didn’t want to step on any toes by appearing to take these people’s attention. I understood, and was grateful for the informed local perspective. But, still, frustrating.

Waiting...

Rene tries the tardy Mutuelle official’s phone, with no response...

Waiting…

She arrives! We can go! But first, the team decides we should look at the Twa resettlement project located next to the cell office. The Twa, sometimes referred to as a pygmy group (though they seemed normal height to me) are the smallest of Rwanda’s 3 “ethnic” groups.

We went and surveyed the Twa settlement. A broken door and they need a latrine. So did I. I died a little inside as my bladder nearly ruptured.

After 2 hours of sitting around, we finally left.

On the way back, we passed through the small town of Gwanda Riushya. Hikers park their vehicles here before they climb the nearby Virunga range volcanoes. With the Mutuelle meeting date for the next week set, we decided to inform the locals. We parked the Land Cruiser, and a group began to grow, curious at what we were doing/would say. Rene smiled, “this is grass roots organizing.” Note to self: Grassroots organizing is easier when your presence draws a crowd.

Rene and Elie said a few words and we were off again.

Now began the serious descent to Shingiro. I was smushed in the back of the Land Cruiser with 8 other people. The back of the Land Cruiser has narrow benches on either wall, facing each other. Maximum capacity, Zack has told me, is however many can squeeze in. So I guess I should have been happy that there were only 8 people in the back. As my legs fell asleep, this probably wouldn’t have been consolation. I am still learning things about the best place to sit in the Land Cruiser. On the way up to Mudende, I sat shotgun, which is the best spot. On the way down I discovered a basic rule of thumb for sitting on the benches in the back of the Land Cruiser: when you are mostly going uphill, sit near the front. When you are going mostly downhill, sit near the back. The key is to ride on top of everyone else, and not be ridden.

The dreaded back of the Land Cruiser.

Unfortunately, as we descended toward Shingiro, I was in the front of the back, with 3 people uphill of me. Ugh. At this point, the combination of altitude and my desperate need to relieve myself was inducing some serious claustrophobia. Rene sat in front, happily snapping pictures with my camera. We slowed down several times for him to get better shots of Shingiro from above. My bladder screamed: Ahhhhhhh!

Finally, in a ride that seemed like an hour instead of twenty minutes, we rolled back into Shingiro. I ran into the new Global Fund building, and found the restroom. How do you spell relief?

I met up with Monique who was taking notes on a community health worker (CHW) training session. After our utter lack of turnout at Mudende, I was reminded that with trained CHWs and a system for deploying them, such a problem should never occur again. After a seemingly wasted morning at Mudende, I have the personal experience to know the value of such a system.

While I came away from the morning with my grand ambitions somewhat tempered, I took from the experience a perspective which will allow me to actually have an impact. The wild dreams and fantasies are gone, mostly. I know more of the reality of Rwanda – its poverty, its frustrations, but also the enormity of good that can be accomplished.

Holy Guacamole

2009-09-15T13:20:00.001-07:00

Jean D’Arc relayed an interesting anecdote to us one morning as we drove up to Shingiro. We were discussing food and, of course, I touched on my love of avocados. Apparently it is very hard to find avocados in the Musanze District. The locals believe that avocados cause HIV.

The reason why hilariously illustrates the leap of logic from correlation to causality.

Avocados are a staple food in southern Rwanda. When migrant laborers, soldiers, and truck drivers from Musanze returned from working in southern Rwanda, people noticed that these groups were more likely to have HIV/AIDS. Because the biggest difference in their lives was what they ate, these people assumed it was the avocado that was causing HIV.

Just remember kids: if it’s casual, it might also be causal.

Tell Me More

2009-09-15T13:17:00.000-07:00

My name is Michael Rossiter. Well, my legal name is Michael Brian Sloan-Rossiter. But let’s keep things simple.

I grew up outside Boston and recently moved into an apartment in the South End of that city. I spent four happy years at Dartmouth College in Hanover, New Hampshire. I studied trade, development economics and government. I graduated in June of 2008 and moved back to Boston.

After college, I started a job at a firm that provides consulting services to private equity funds. Mostly, the firm generates due diligence reports on an acquisition target’s market, market position, and customer base. Also, I snuck onto a couple of strategy projects, which I really dig. It is an engaging and interesting job and the fast project timelines has allowed me to look at a large number of companies in a short period of time. I think I was actually proving to be useful towards the end of my first year. Not bad.

So, to take stock, after a year in the real world I had a good job, a nice apartment, and great friends. Life was easy…I hate – no, I f***ing despise – easy.

So about a month and a half ago, I sat in my cube when a gchat message popped into my reality. It was from Zack Scott, my freshman and sophomore roommate. Zack had been diverted to Rwanda for some do-goodery by the financial consulting firm he was planning to start with. “I think we’re hiring someone to come for the rest of the year. you interested?”

I was working on something while I chatted and I didn’t think at all about my response. It was, in the terminology of Malcolm Gladwell, a “blink” moment.

“Yeah. Tell me more.”

So I type these words from Musanze, Rwanda. For the next four months I will be taking a hard look at the workings of a health center that serves the 30,000 people of a rural, low income community in northwest Rwanda.

Please expect this blog to be a lot different in tone and content than this post. Mostly, I will be posting about Rwanda and the project, CCHIPS. Check out the project website, http://www.wwhps.org . Also, I will be cross posting a lot of what I put here on the Field Blog on that site: http://www.wwhps.org/field-blog.