Tag Archives: Health

A bamboo construction in her family's yard helps six-year-old Tai walk on her own. Photo by: Anna Bella Betts Photography.

Disability is not our priority area

An open letter to organisations that don’t fund disability-focused projects.

Dear Funding Body Rep,

Thank you for your reply to our expression of interest. In rejecting our submission, the main reason you gave was, “Disability is not our priority area.” I’d like to explain why it has to be.

There are over one billion people with disabilities in the world.  And in the poor countries where you work, up to 20% of the population has a disability. If you ignore 20% of your target group, you’re not really working to help the most vulnerable.

You say, “Our focus is health. Disability is not our priority area.” But the two are inextricably linked.

Of those with disabilities, 98% do not have access to basic health care services. However, because of complications that arise from disability, and the fact that they’re usually poorer than most, people with disabilities are usually in greater need of health services. Amongst the people that need services the most, they are often the most excluded.

You say, “Our focus is education. Disability is not our priority area.” But the two are inextricably linked.

This is Ouk Ling. He’s a child I met recently who lives outside Siem Reap, a town in the north of Cambodia. From looking at him, most of the people in Ling’s village thought that he was stupid. After receiving a basic health care service, speech therapy, he has been able to show that he isn’t stupid, he just has a communication problem. After some simple therapy, he’s now going to school and has worked his way to become second in his class. Hopefully, one day he will use his education to be a contributing member of society.

Photo credit: Anna Clare Spelman
Ouk Ling with CABDICO Child Rehab Officer Chea Phearom. Photo by: Anna Clare Spelman.

Ling is one of the lucky ones. 90% of children with disabilities will never go to school. If we want to reach universal primary education, Millennium Development Goal Number Two, then we all need to do something about this.

Of course, getting children to school is not enough. We also need them to learn.  Statistics from around the world have shown that funds, controlled by people such as yourself, have helped an enormous number of people. Currently, 84% of adults in the world are literate. This is a great achievement.

However, the global literacy rate for adults with disabilities doesn’t make for pretty reading. 97% are non-literate. For women, it’s even worse: 99% of women with disabilities are non-literate.

You say, “Our programs must be gender-inclusive. Disability is not our priority area.” But the two are inextricably linked.

Is your work inclusive of one of the most marginalised groups of women in the world? Women and girls with disabilities face triple discrimination: they’re female, they have a disability, and they’re often poor.

If we really want to improve the lives of the women in this world, let’s start with the ones who are the most vulnerable.

Here’s what one woman had to say about her own experiences:

“I think the outside world does not really understand what the real difficulty is for women with a disability. I repeat again and again, for women with disability, it is really hard to live, so please include us.” 

Josephine Namirimu, from Uganda's Young Voices program.
Josephine Namirimu, from Uganda’s Young Voices program.

Would you be comfortable telling this woman, “Disability is not our priority area?”

There is a wealth of information out there on how to better include people with disabilities in development and healthcare programs. This is not to say that including them in mainstream programs is the panacea. We also need resources to do disability-specific work.

However, it’s not a lack of resources that’s the problem. It’s the will. There are over 1 billion people in the world who must become our priority.

Yours sincerely,

Weh Yeoh

Co-Founder, WhyDev


Last Week Today: 8 August 2014

Don’t have time to scan the web for global news? Want to know about development events and jobs? Sick of having a million emails in your inbox?

Want to know about development events and jobs? Sick of having a million emails in your inbox? – See more at: http://www.whydev.org/8-august-2014-the-week-in-links/#sthash.xI7M0fJI.dpuf
Don’t have time to scan the web for global news?
Don’t have time to scan the web for global news?Want to know about development events and jobs? Sick of having a million emails in your inbox?

We’re here to help.

Today we’re launching Last Week Today – a weekly post that has the best stories, news, events and jobs in global development.

Now you can breathe a sigh of relief. Last Week Today is all you need.

So grab a coffee, sit back, and enjoy the week’s best in global development.

The week in news

Niger is the French word for Nigeria, right?


CNN’s on-air mistake has reignited discussions about ignorance of developing countries, and brought attention to the network’s past misplacing of Ukraine, and Hong Kong, and London, and…

Washington, D.C., was abuzz this week with President Obama’s parade of autocrats (aka, the U.S.-Africa Leaders Summit) which brought over 40 heads of state to the White House.

In the rest of the world: this was a tragic week in parts of China and Nepal, and Afghanistan’s election crisis is worsening. South Sudan is facing a triple threat of violence, famine, and cholera. The ebola outbreak is reportedly spreading, though not as fast as our fears of it.

It’s not making global headlines, but our love affair with coffee may have some seriously damaging environmental consequences.

And in this week’s edition of is-this-for-real, USAID has evidently been sending young Latin Americans to incite rebellion in Cuba, using the cover of HIV-prevention workshops.

The week from the blog

NGOs can learn from YouTube celebrities

Most NGOs these days blog, tweet, use Facebook – but not many of them use video effectively. Our Communications Director Rachel Kurzyp explains how organisations could pick up some tips from (who else?) the celebrities of YouTube.

Starving for awareness

The UN is feeding refugees a starvation diet: 850 calories a day. When Francisco Toro found out about it, he didn’t “like” a post or order a bracelet. Instead, he ate a tiny bowl of sorghum and lentils – and nothing else.

The gendered lens is always a good bet for looking smart to your development friends. Cartoon by Kirsty Newman.
The gendered lens is always a good bet for looking smart to your development friends. Cartoon by Kirsty Newman.

The week in links

Tips for looking smart to development geeks | Kirsty Evidence

New research suggests there are three types of female aid workers. | Women in Aid

Africa’s rising, Africa’s falling…but it’s mostly rising. | The Washington Post

Two theories on why we’re so obsessed with giving away our old stuff | Blood and Milk

Beggars can’t be choosers, but are they really beggars…? | Good Intentions (courtesy of USAID’s Center for International Disaster Information)

Can volunteers really cause harm? | AidSpeak

No doubt about it, 850-calorie-a-day food rations aren’t enough to survive. | 850 Calories

Is Bitcoin the next big thing in financial inclusion? | Development Channel

Are health gains in developing countries really helping the poor? | Brett Keller

New evidence for the impact of education on women’s health | Humanosphere

The week in events

Complex? Nah just a Tuesday | Melbourne

Always on the go? Have a version sent straight to your inbox every Friday.  Just sign up for the Last Week Today newsletter.

Good intentions are enough – to ‘nearly kill’ a local kid

By Anonymous

Given the nature of today’s anonymous post, WhyDev is unable to verify the details of the story below, but we believe it is valuable to publish given the ethical questions it raises. Names and identifying details have been changed to protect the privacy of individuals.

What does ’saving‘ a child really mean? Ask 10 people and you’re liable to get 20 different answers.

Here’s a situation where this question was implicitly asked but I’ll let you decide whether or not anyone was ’saved.’ As extremely discomfiting as this situation is for me, I’m putting it out to the wider development community with hopes of starting a conversation about how we can stop similar occurrences in the future.

I am currently affiliated with an NGO that works on health systems strengthening in East Africa. Pretty standard stuff – malnutrition, maternal mortality, village outreach, and the like. Recently, the founder turned the formerly-secular NGO into an explicitly-evangelical one, and with the shift came missionaries dedicated to ‘soul harvesting’ and ‘crusading.’

But ultimately, this is a story about an 11-year-old boy, Micah (not his real name). He was found by the side of the road one evening and was brought to the nearby health centre, where one of the missionaries happened to be working. We don’t know exactly how he ended up there, though the working hypothesis was that his mother tried to poison him and left him for dead. We’d later learn that this is almost certainly not true.

Whatever string of events led Micah to the side of the road, he was in rough shape and alone at the hospital. The missionary wanted to help, made phone calls to community members, and became involved in his case.

Micah required a higher level of care, so the missionary insisted that he go to a better-run private hospital, all expenses paid by the NGO. The missionary then had the police hastily write up a note giving our organisation the right to take the child, so he went into surgery and came out with one less appendix and one additional eight-inch incision on his abdomen.

As he recuperated, the conversation shifted to what was going to happen to him after he was discharged; a group of at least six members of the organisation, along with one community member, tasked themselves with deciding Micah’s next home – with no single person responsible for the decision or for his care. Relatives were unreachable and the paucity of available information meant that no good option seemed to exist; orphanages were discussed, but shot down for not being ‘right’ and for taking too long to accept him.

And so the missionaries decided that, while they attempted to sort out proper placement, he would stay with us. They wanted to save a child. Please do not misunderstand me – all of them are extremely kind, caring people who only had the absolute best of intentions.

But, that’s exactly the point – as we all know, and as this story will show, extraordinarily good intentions can be extraordinarily dangerous.

Before continuing, it’s instructive to note a few things. First, a police report was never filed in a case of what was assumed to be attempted filicide; while we now know that it wasn’t, at the time that was the working assumption. In some areas, it would be commonplace to forego police action; here it is not. The missionaries did receive a handwritten letter giving them the authority to take the child to the private hospital, but that was the extent of police involvement. A suitable post-discharge plan was discussed but not seriously considered by the group of seven; many orphanages were available, but never truly considered as an option.

So, Micah was taken from his community into an NGO home that is teeming with foreigners and bereft of other children. He was placed in the care of people who neither share his language nor his culture. While it’s a little facetious to say that he was ’kidnapped‘ (technically, the police did give consent; whether it was theirs to give is a separate, but important, question to ask), it is fair to ask whether this was truly in his best interest or if it was appropriate to do.

If this was the end of the story, it could probably serve as the start of a good discussion on the promise and the peril of good intentions and whether these actions are ethical or advisable.

But it’s not the end of the story.

Micah arrived in the late afternoon and walked into a room full of foreigners. For the next hour or so, a member of a nearby church translated as the missionaries explained what was going on and asked a number of questions about what had happened to him. It was clear that he was extremely uncomfortable, and understandably so.

Micah became the ’house boy,’ and as no one was specifically accountable for his health and wellbeing, no one was responsible for him. None of us are able to speak more than a few words of his language, so we got by with a few hand signals. He warmed up to us, watched television, and ate.

But not in that order. By the time someone noticed how much food he was eating – including things he probably had never digested before, like burgers and chips – it was clear something was wrong with him. Micah’s a skinny kid, but he looked six months pregnant; he was eating too much and it was all staying in his now-distended stomach. With no one accountable for his care, this was allowed to slip by for far too long.

A day later, Micah was in extreme pain, so the missionaries took him to the hospital – the same one he had been discharged from days earlier. The doctor put an emergency nasogastric tube through his nose to reduce the distension; after the tube was in, the doctor said that his stomach ’deflated like a balloon.’

He later said that Micah’s stomach was dangerously near rupture, and that he was, unequivocally and without exaggeration, ’near death’ and ‘nearly killed;’ his stomach could have perforated or his abdominal distension could have put too much pressure on his lungs.

Micah spent the week writhing in discomfort, as the nasogastric tube kept him from distending. After myriad tests and consultations, the surgeon said that the valve between the stomach and intestines was not opening; this could require surgery to fix. But ’could‘ does a lot of work there – the condition could also work itself out in time.

In other words, a decision had to be made, but the medical officer of the NGO was out of the country, and we could not get a hold of him. He’s from the country but not the region, and had not been involved in Micah’s case in any meaningful way. Ultimately, the surgeon had to leave for the airport, so Micah didn’t have surgery that day.

This was a remarkable stroke of good luck, as the doctors were able to take the nasogastric tube out, and Micah began to eat. Bit by bit, his strength – and his smile – returned, and he was discharged days later, no surgery necessary.

He is back in our home once more, but this time one person is responsible for his health. I’ve had more than a few conversations with that person about the need to find him a suitable home as soon as possible, and it seems to have had an effect. I’m hoping he gets better, and finds a new home, soon.

So, uncharitably, it could be said that a NGO – with the best of intentions – took a child from a hospital and was the proximate cause of his immediate readmission and ’near death‘ experience. But even the charitable version leaves much to be desired: an outside group took ownership of a local child, failed to understand the risks of doing so, failed to take care of him, and – most importantly – failed to keep him safe.

There’s no question that his life was in a precarious situation before the missionaries intervened; he was a sick child who desperately needed help. But did he need help from his own community, or from outsiders who felt they were doing the right thing by removing him from it?

It’s possible that Micah’s community would have allowed him to overeat, or would otherwise failed to provide him the appropriate atmosphere conducive to convalescing. With a pyloric valve issue, it’s possible that, eventually, he would have returned to the hospital.

But would he have nearly died? Would major decisions about his health have been made by outsiders?

Are such situations simply unlucky or avoidable? Is this a one-time, isolated case of hubris, or is it proof positive for the broader claim that outsiders – even with the absolute best of intentions – are fated to cause more harm than good?

What if the child would have recovered as normal – how does that change conceptions of right and wrong? What if my organisation would have done a better job of taking care of Micah – then would it have been OK?

I don’t have answers to those questions, and am grappling with them myself. I only know a few things: this situation leaves me deeply uncomfortable, deeply furious, and deeply ambivalent about my tangential relationship to it, and it seems to me that no child was saved.

In this case, good intentions were enough – to nearly kill a local kid.

Bar Graph

MDG 5a: An update on maternal mortality

With two years left, it is highly unlikely that Millennium Development Goal (MDG) 5a – in the clunky verbiage of the UN: “Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio” – will be met worldwide.

But, substantial progress has been made, which in human terms, means that hundreds of thousands of maternal deaths have been prevented. It’s worth taking a step back to understand the scope and scale of the problem, and to think through the interventions that have been successful in myriad developing and developed countries.

The Maternal Mortality Ratio (MMR) is calculated as the number of pregnancy-related deaths (from any point in the pregnancy to 42 days post-birth/termination) per 100,000 live births. In 2010, an estimated 287,000 mothers died from pregnancy-related causes, or 210 deaths per 100,000 live births; it’s an almost 50 percent reduction from 1990, when an estimated 543,000 mothers died, or 400 per 100,000 live births.

These roll-up figures mask a wide variation in the distribution of maternal mortality. In 2010, an astounding 99% of deaths occurred in the ‘developing world’ (56% in sub-Saharan Africa alone), and the MMR in developing countries is, on average, 15 times higher than in developed countries. According to the World Bank, the country with the highest MMR in 2010 was Chad, the lowest Estonia, at 1,100 and 2 per 100,000 live births respectively. A chart showing the 40 countries with the highest MMR is below, with the United States – at 21 – added for reference:

Bar Graph


Scan the list of countries and it becomes clear that the MMR problem is clustered in Africa, with few exceptions. There’s wide variation among these countries too. The question is: why?

Worldwide, the leading direct causes of maternal mortality are: Post-Partum Haemorrhage (PPH); Pre-eclampsia and eclampsia; and sepsis (see the Figure 2 below). Together, these three conditions account for 60% of maternal deaths.

Pie Chart
Figure 1

At the patient-level, interventions to prevent or treat all three are well-understood, cheap, and straightforward:

  • Prevention of PPH is facilitated by following a protocol known as Active Management of the Third Stage of Labor (AMTSL), which involves the administration of an uterotonic (e.g., oxytocin, ergometrine, misoprostol) and massaging/monitoring for two hours post-birth. A Randomized Controlled Trial (RCT) found that women who received AMTSL experienced PPH 6.8% of the time vs. 16.5% with passive/conservative management; almost a 60% decrease
  • Treatment of pre-eclampsia and eclampsia involves the injection of magnesium sulphate, a cheap compound (in the West, the non-pharmaceutical preparation is known as Epsom salt). A highly-regarded RCT found that magnesium sulphate halves the risk of eclampsia in pregnant women
  • Prevention of puerperal fever*, or sepsis more generally, is a matter of maintaining proper sanitation before, during, and after a birth. If a mother develops sepsis, a full course of antibiotics can be administered as treatment.

Here’s what’s clear: the devil isn’t in the details. It’s in the diffusion of pharmaceuticals, health care workers, and knowledge through health systems, and in improving those systems holistically. It goes deeper than the health system of course; to administer AMTSL, for example, requires the drug being available (partially a supply chain/regulation issue), a health care worker who is trained to administer the drug (an education issue), and a health care worker who has the time to administer the massage every 15 minutes for two hours (a financing issue). And keep in mind, that’s only if the mother has a trained health care worker by her side, which in sub-Saharan Africa puts her in the minority, with only about 46% of births attended by skilled health personnel in 2008.

The complex task of reducing maternal mortality demands a multifactorial solution that draws on a wide coalition of government departments and private organizations; and each country has to find a solution that meshes with its own cultural and structural realities. Nevertheless, there are broad themes that transcend these inter-country differences and show up in the success stories of many positive deviants:

  • Increase access to family planning and contraception
  • Strengthen demand for antenatal check-ins through education campaigns, conditional cash transfer programmes, or easier access to skilled professionals
  • Increase the percentage of births attended to by a skilled professional; ensure skilled professional is able to provide necessary care (e.g., equipment, pharmaceuticals, knowledge) for non-complicated birth and is able to refer complicated cases
  • Ensure Emergency Obstetric and Neonatal Care (EmONC) services are comprehensive and of high quality, and that health centres are staffed with skilled workers; stocked with maternal medicines, antibiotics, and proper equipment; and accessible to remote populations
  • Establish or strengthen monitoring systems to highlight successes and areas of opportunity.

All of which goes a long way towards our understanding of why some countries have already reached MDG 5a and others are unlikely to do so; the interventions require sustained political will, ‘soft’ infrastructure (e.g., regulations, communication), consistent funding, and a systems approach to process improvement. Unfortunately, it may take more than 20 or 25 years to build out this basic scaffolding on which to build sustainable change.

The imminent failure to reach the goal of reducing the MMR by 75% by 2015 shouldn’t obscure the fact that there are hundreds of thousands of mothers alive who, without the focus on maternal mortality, may not be otherwise. Much more can – and will – be done in the next two years, and in the next two decades.

In many ways, 2015 is just the start.

Text Box
Figure 2


*If you’re a public health or history of medicine wonk, you may recall that puerperal fever (or childbed fever, as it was known) was the disease that led Ignaz Semmelweis to call for basic hygiene measures in his Viennese hospital pre-Germ Theory of Disease – and was promptly rejected from the establishment for his heresy. As one contemporary doctor put it, “Doctors are gentlemen, and gentlemen’s hands are clean.”



Goals are good, but do the MDGs need to be simplified?

If the recent US presidential campaign felt more acrimonious and hard-fought than ever before, remember, there’s probably good news for global development. According to the UN, the world has met two critical Millennium Development Goals (MDGs), including halving extreme poverty and doubling access to clean water. Although success is not evenly spread and some of the MDGs will probably not be met, we have considerable reason to celebrate the most significant gains we have seen in our lifetime.

In order to ensure that this progress is equitable and accelerating, our goals for the post-2015 framework must take a different shape. Simplifying the MDGs to just four goals encompassing global well-being, extreme poverty, health and climate change will make the MDGs more memorable and reportable.

Although global well-being may not seem to fit in the context of the MDGs, it makes sense to measure what we’re actually trying to impact by examining the degree to which we’re improving lives. This will require new resources and thought around what is an acceptable measure of well-being, as Bhutan’s interpretation of “Gross National Happiness” illustrates, but these are details that deserve to be debated in the full light of greater research and commentary. Importantly, creating an MDG that aims to raise overall global well-being will not only spur research and aid funding to more accurately assess whether our anti-poverty efforts are achieving this goal, but also receive attention from some who may not otherwise pay attention to global development.

But in this respect, attracting attention to the MDGs, simplifying our broader aims to just four will give us more freedom to make the MDGs a cause to advocate for in and of themselves. Currently, activists advocate for the end of AIDS or the capture of Kony, but few clamour for the achievement of MDG five, if anyone can even name what it actually is (improving maternal health). But by consolidating our aims to a distinct four, MDG progress can be sped along by activists advocating for the end of climate change, for example. Making the MDGs marketable for the purpose of activist involvement isn’t about reaching for inclusion where it doesn’t exist, but finding alternatives to waiting for governments to chip in.

And though I’ve earlier called the MDG gains the most significant of our lifetime, exaggerating successes and drowning in failures is probably an unhelpful trait of development writing. Although it’s wonderful that extreme poverty has been halved since 1990, China’s recent growth has much to do with this, which is largely not a product of humanitarian development dollars. If our post-2015 MDGs are destined to merely measure our overall progress against poverty, then there is nothing wrong with claiming success when we succeed as a result of a factor we didn’t expect. But this isn’t the goal of the MDGs. The MDGs should seek to compel individuals and nations to up their contributions to development. This is only possible if we judge success by the amount we increase our commitments every year—in dollars, contraceptives, bed nets, medicines, and anything that improves lives.

Certainly, this approach will encourage help of all kinds, but it’s crucial that we aren’t misled to believe that charity given regardless of context or need is a victory. The MDGs should not just be a reflection of where we wish to see the world in the near future, but how we should prioritise our spending. For example, the Copenhagen Consensus, an organisation that attempts to gauge which development interventions are the most cost-effective, ranked providing malaria treatment as one of the best ways to save lives and improve health in 2012. Although HIV/AIDS is arguably a more pressing issue than malaria if judged by a simple number of deaths, money spent treating malaria will have a greater impact than treating HIV/AIDS according to their research. Many people are understandably uncomfortable with the premise of determining who lives and dies on the basis of cost-effectiveness, but compassion does not justify ineffective approaches.

While the MDGs may not contain the adrenaline and energy of a costly election, activist engagement may allow us to achieve success where government funding hasn’t. Four MDGs, encompassing most of the interests of the current MDGs, will pull us through every MDG success, every failure and every unsatisfying outcome in between.



Tobacco, Poverty and the Need for Global Action

The recent High Court judgement in Australia upholding legislation to enforce plain packaging for tobacco products provides a good opportunity to look at the impacts of tobacco in low and middle income countries, and what’s needed to stem the tide of poverty and mortality they cause.

Image credit: iStock photo

It’s increasingly recognised that non communicable diseases (NCDs) are among the greatest threats to global public health. According to the WHO, in 2008 NCDs (consisting of cardio-vascular diseases, chronic respiratory diseases , cancers, and diabetes) were responsible for 63% of all deaths worldwide. The key source for statistics on the burden of NCDs – the WHO’s Global Status Report on NCDs 2010 – presents clear evidence that NCDs primarily affect low and middle income countries. In 2008, 80% of all NCDs deaths occurred in low and middle income countries – an increase from 40% in 1990.

Tobacco use is a major driver of the NCD epidemic, and is one of the single biggest public health threats the world has ever seen. Tobacco causes around 6 million deaths each year, and ultimately kills around half of its users. 10% of people killed by tobacco aren’t even smokers – but instead are killed by exposure to second hand smoke. Importantly, 80% of all smokers are in low and middle income countries. Tobacco use isn’t only a health problem, but is actually a development issue. Tobacco users who die prematurely deprive their families of income, raise the cost of health care and hinder economic development. Money spent on tobacco would obviously be better spent on healthy food and education.

Over recent years there has been increased momentum in global tobacco control. In February 2005, the WHO Framework Convention on Tobacco Control came into force, and since then it has become one of the most widely embraced treaties in the United Nations’ history, with more than 170 Parties covering 87% of the world’s population. The WHO Framework Convention is an important contribution to global public health – it reaffirms the right of people to the highest standard of health, provides legal foundations for international health cooperation and sets high benchmarks for compliance.

Much more, however, is needed if we are to stall and reverse the growth in tobacco use and NCDs more broadly. One of the key elements of the tobacco threat, as countries like Australia recognise and address this problem, is that tobacco companies are adopting increasingly aggressive strategies to increase their infiltration of developing countries. In countries like China, India and Indonesia, overall rises in economic development have led to an increase in tobacco use. A good example of this is the Tobacco Asia Conference, which is scheduled to be held in Indonesia on 19 September 2012.  A coalition of civil society groups came out strongly against this conference, noting that ‘The conference committee deems Indonesia a tobacco-friendly market with no smoking bans or other restrictions or regulations compared to other ASEAN countries. That is an insult to our nation because it means we are supporting death, and we are urging the government to ban this conference.’ Such protest and awareness raising has a vital role to play in ensuring that the tobacco industry and governments are held accountable and that the damage to low and middle income countries is halted.

Image credit: hakaider

It’s also vital that the tobacco control lessons that have been learnt in the developed world are shared with low and middle income countries. In July 2012, the Australia India Institute Taskforce on Tobacco Control launched a report outlining steps that could be taken in India to reduce the use and impacts of tobacco products. Drawing upon achievements in Australia, the report outlines how legislative change, public education, enhanced Government accountability, plain packaging and pictorial warnings will help reduce the roughly 1 million Indians who die from tobacco use each year.

It’s also important that tobacco control is seen as a core element of efforts to improve global public and eliminate poverty. One way this can be achieved is through elements of tobacco control being funded through the aid programs of developed countries like Australia, the United States and the United Kingdom. AusAID has started funding tobacco control in the Pacific, including through activities like surveys on youth smoking, promotion of the Framework Convention on Tobacco Control, and interventions including enforcement training. AusAID is also providing funding to address the disease outcomes of tobacco use, including cancer. This funding is currently focused on the Pacific, and it’s important that Australia’s commitment broadens to include other countries with major tobacco and NCD problems in Southeast Asia and beyond.

Finally, it’s vitally important that international development agencies embrace the need to tackle tobacco use. At present, programs to reduce tobacco use and control NCDs are largely limited to agencies that have a specific focus on these issues. The World Health Assembly’s decision in May 2012 to adopt a new global target of a 25% reduction in premature mortality from NCDs by 2025 was a step in the right direction; as was the inclusion of NCDs in the Rio + 20 Earth Summit’s outcomes document The Future We Want. What’s needed now is for tobacco control and NCDs to be placed at the centre of the international development discourse. The Oxfams and World Visions of the world need recognise and respond to the problem, and the post 2015 MDGs need to have a clear commitment to this crucial public health and development issue.


Education still a long way off for children with disabilities in poverty

It’s a great idea for a movie. A political drama. George Clooney or Matt Damon as male lead, and there’s a young, feisty, female journalist who gets caught up in it all. The opening scene spans a meeting room high up in skyscraper land, with a marble round table, iced water jugs and leaders of a big global development Bank.

Disability is not the only battle for kids like this. © 2011 CBM Australia, Photo: Christoph Ziegenhardt.

“Gentlemen, you should be proud,” says the silver fox, “This policy forges the path to education for the poorest of the poor.”

Clapping and shaking hands all around.

Cut to the brilliant green and brown of a remote village high up in Indonesia’s mountains. Children, gorgeous and laughing, walk kilometers of terrain to a tiny, one-teacher school. The camera pans back to the village, where a little girl stares wistfully after them. The shot widens to show that she has clubfoot; her feet twisted inwards. As opening credits scroll on, we know there is no way she could walk to school…

I haven’t worked out the complete script yet, but there are plenty of true stories to draw from. One billion people in the world have disabilities, and around 80% of them live in developing countries like Indonesia. In fact, in the world’s poorest places over one in five people have disabilities.  These people live with much more than just physical or mental impairments. As my “little Indonesian girl” character would portray, people with disabilities experience huge barriers in participating in education, employment and community life.

Barriers exist for people with disabilities in all societies, but are steepest in poorer communities where access to these activities is often limited anyway. A child born with clubfoot in Australia will generally get treatment at birth to straighten and strengthen her legs, and still go to school, socialise and work with her peers. The little Indonesian girl, however, presents the reality in many developing countries.

In these places, children born with clubfoot will never receive treatment for this. Walking, if possible, will always be painful, and she could never travel far. In many communities her impairment would also be seen as a curse. She would likely face a lifetime of stigma and exclusion from her community, who assume that because she has a disability, she has no potential.

If there was a movie, this little girl’s story would show us how poverty and disability create a vicious cycle: being poor generally limits access to health care, good nutrition and safe conditions – which increases the likelihood of acquiring a disability.  And having a disability generally limits access to education, employment and community – which increases the likelihood of being trapped in poverty.

Clearly this movie is a drama. It’s a dramatic fact that children with disabilities make up one-third of all children in developing countries who should be in school but are not. What isn’t so clear is how this dire situation can be developed into a Hollywood ending.

Cue for us to cut to the silver fox in the skyscraper.

Some of the big players in development are coming to recognise that people with disabilities are extremely vulnerable and excluded from their projects. How this recognition gets the little girl with clubfoot to school is more complicated. RESULTS International (Australia) recently released a report examining how the World Bank, Asian Development Bank and AusAID include girls and children with disabilities in education programs they fund in Papua New Guinea, Indonesia and the Philippines. The report finds that while all three agencies consider disability in their high-level development policies, “on the ground” many children with disabilities are still not getting to school.  Some progress has been made—particularly by AusAID–but children with disabilities continue to be profoundly excluded from education. And so the scene is set for the tale of the silver fox and the little village girl.

To be honest, I don’t think I’d like the movie. It would have a twee love plot and some expendable character I fancied would die. Then there would be the inevitable contrast between the skyscraper and village, reinforcing unhelpful paradigms of “us” and “them”, “benefactor” and “beneficiary”, “problem” and “solution”.

But I would still probably go to see it. Because when millions of the world’s children are facing such extreme discrimination and exclusion, you need to take what you can to get the message out there.

Which is why I’m asking you to think about this: Would you have gone to see the film? Would you get teary at the injustice that the little girl endures? Would you spend the trip home ranting about the laudable development banks writing toothless policies from their air-conditioned skyscrapers? Would you Google some combination of “disability poverty Indonesia education” when procrastinating at work the next day?

Or, even if you think the movie sounds like the worst thing since the Titanic, are you horrified by the fact that 70% of children with disabilities in Indonesia do not go to school?

If so, don’t let this storyline just be an overlooked opportunity for Matt Damon to get an Oscar. Movie or not, there are still millions of children in the world being denied their rights because they have a disability. So get teary, rant, Google, find out more about ending the cycle of poverty and disability.

Their stories may not make it to the big screen, but these children still deserve the chance to write their own happy ending.


This article first appeared in the Angry Cripple column of The Punch.

To find out more about the cycle of poverty and disability and what you can do about this, visit End the Cycle.


Are you psychologically equipped for working in aid and development?

White Paper Series by Alessandra Pigni

“The idea that psychological well-being is a luxury is right at the root of the problem. The mental health of field staff is every bit as important as their physical health. Proper preparation for the psychological stresses of field life should be taken as seriously as pre-mission medical assessments and associated measures to prevent/treat illness in the field.”

(Robyn Kerrison – human rights/protection advisor, currently working in Haiti) 

Over the last months I have been collecting stories, reflections and suggestions from humanitarian professionals on the importance of staff-care, pre-deployment psychological preparation, burnout prevention training, field support, coaching and mentoring and post-deployment care. HQ and field-staff have lent their voice to this white paper series, which provides an analysis of the needs in the field, as well as the types of interventions that could be of help, including mindfulness training.

Encouraged by my dear friend Jennifer Lentfer at how-matters.org the first chapter of the White Paper Series on the psychological health of the precious people who work in aid is now out! It provides the background and purpose of the whole series. I have chosen to release the twelve papers over several weeks, in order to give readers the time and space to process the material and reflect upon it.

Below is an overview of the series:

  1. Provides the background and purpose of the white paper series.
  2. Offers an overview of the issues in psychological health faced by aid workers before, during, and after field deployment.
  3. Gives an overview of the concepts of mindfulness and how they may apply to aid work.
  4. Focuses on the recruitment and hiring processes of aid workers.
  5. Focuses on the pre-deployment phase, and the type of psychological preparation required.
  6. Focuses on the importance of personal awareness in the field.
  7. Explores the role of teams and team conflicts in staffʼs psychological well-being.
  8. Examines the organisational culture that permeates humanitarian agencies.
  9. Focuses on burnout and reaching ʻa breaking pointʼ.
  10. Examines practices that support aid workers while in the field.
  11. Provides an open conclusion with recommendations for action.
  12. Offers a list of useful resources on staff care, psychological support and mindfulness-based interventions.

In each of the papers, the voices of aid workers in the field are included (always in italics), along with their personal stories. They discuss the staff-care needs that arise during a mission, often describing the predominantly tough “humanitarian culture” that permeates agencies. But these papers do not only collect, describe and analyse the evidence offered by frontline professionals and volunteers. Each paper also provides conclusions and suggested interventions: action points, priorities and policy changes, highlighting how the lack of training and staff-care in humanitarian programmes can turn into an occupational hazard for employees and their agencies.

In particular, the concepts and practices of mindfulness are introduced in their relevance to the problems that may arise in the field, highlighting the significant difference that they can make to standard NGO training, procedures and management. Recommendations for developing psychological awareness, better staff retention, care and support before, during and after the mission, as well as a list of useful resources can also be found in a separate section of the white paper series.

Donors and HQ staff may be particularly interested in following this white paper series. Frontline professionals who know all about burnout, stress, trauma, loneliness, isolation and depression in the field, and the urgent need of doing something about it, may recognise their voices in it. I am convinced that “changing the world starts from within”, and that successful projects on the ground derive not only from professionally competent, but also psychologically healthy staff. How we feel within ourselves has an impact on how we engage with the world. This is no small matter.

Much is to be discussed, changed and improved in our aid community around staff-care. Starting from ourselves I feel is a good place of enquiry. Feedback and comments are most welcome, and so is your participation in the Frontline Burnout Prevention Group on LinkedIn.

To download the first paper of the series please click below (the bibliography is available for download as well so you can refer back to the various sources)

#1 – Background and purpose of the white paper series.

Bibliography – A List of Useful Resources

The remainder of the series will be updated section by section and downloadable from Mindfulness for NGOs.


This is a reposting of an original post on Mindfulness for NGOs.


What’s happening to the rights-based approach?

I wanted to share an incredible article I recently ran across, by Rosalind Eyben on Contestations: Dialogues on Women’s Empowerment:

“Recent years have seen a marked shift in official development discourse, with less emphasis on a rights-based approach and more on an efficiency approach to gender equality, a tone set by the World Bank’s 2006 action plan – ‘Gender equality is smart economics’ which a number of official development agencies committed funds to resourcing.  Other equally disturbing trends are emerging, such as DFID’s adoption of the Nike Foundation’s ‘Girl Effect’ theme of ‘stopping poverty before it starts’ by ‘investing in girls’ – an approach that entirely ignores the historically derived structural inequities that are keeping many millions of girls [and boys!] in conditions of poverty.

Nike’s message is a simple one. It is communicated in a slick two-minute animation, on YouTube and at www.girleffect.org. Take a look.  It paints a picture of ‘the other’, living in a situation of dirt, disease and despair. A girl surrounded by flies, taken out of the context of her family, community and country, objectified as the solution to the world being ‘in a mess’. It paints a totally unreal picture of linear cause-effect change. Based on the mantra ‘invest in a girl’ it tells us there is a single, simple solution and we can stop worrying about the historically derived patterns of injustice and inequity in the world. Nor do ‘we’ have to either bother with finding out more about what is happening in the lives of people in poorer parts of the world nor how they perceive their own lives and how they want to make their own futures.

It is a message that is profoundly anti-rights. And it is one that says nothing about where boys – and men – might come into the picture. It ignores notions of justice and equity in relations between people and countries that underpin a rights based approach.  The seeming triumph of the 1990s had been that social justice was seen as a sufficient reason for efforts to be made to secure gender equality. Women’s and girls’ well-being was an end in itself. Today, it is all about calculating the rates of return from investing in a person as if she were a piece of machinery.

Removing the realisation of rights, including women’s rights, from the donor agenda is part of a wider tendency to define development in terms of instruments – immunisations, bednets, numbers of children going to school, quotas for women in parliament – rather than xxx [you choose a good word, I was going to put “the social changes needed to make a fairer world”]. So we see investment in immunisations and bed nets rather than in x and y. This reflects the growing influence of large corporate sector philanthropic organisations and of the big accountancy companies. Technical solutions are sought for what are perceived to be technical problems…”

This is a very important message and distinction, one that is being lost in the midst of ‘randomised trials’ and monitoring and evaluation to ensure that X girls obtain education or healthcare. Yes, tangible results are important, but are we forgetting the rights-based approach, that tries to address the underlying problems of structural inequalities?

The Girl Effect: Well meaning but is it addressing underlying structural problems?

This doesn’t just apply to women’s rights, but in non-profit efforts as a whole. An efficiency approach is more about quantity than quality. It’s about getting more bang for our buck. It’s about saying – “we helped 1000 women obtain health care/education!” Large numbers of beneficiaries sounds good to donors, but what about the quality of the services provided? And the quality of life as a whole for each woman, man, or child we have helped? The long-term impact?

Isn’t it better to invest deeply in one community and ensure they are truly empowered, lifted up, and have an improved quality of life as a whole, rather than to provide piecemeal services, without addressing any systemic challenges? The approach that donors like is more about scaling up, than depth of impact within one community.

Ultimately, devising programs on the basis of being more economically efficient is not a rights-based approach. Think about the death penalty: arguments that putting someone to death is far more expensive than imprisoning them for life do make sense, but what about the deeper moral argument? Saying that reducing prison sentences makes economic sense because prisons are expensive is one thing, but arguing for an improved criminal justice system and abolition of the death penalty on moral grounds is another thing altogether. The moral and rights-based argument, in my opinion, gets down to what makes us human — and is thus far more powerful. It hits at the core of human rights. It’s a rights-based approach.

Is our obsession with indicators, numbers and monitoring ignoring the rights based approach?

Indicators and numbers and monitoring are important, but so is asking people what they really need, and allowing them to have a hand in devising and running projects for their own communities. It’s important not to just focus on the numbers that sound most impressive, but also what is really demanded and needed. What upholds the human rights that each beneficiary has. Even if it costs more, or is less economically efficient, or doesn’t look as sexy to donors.

And so, I agree with Rosalind when she concludes:

“…today, many donors only want to fund projects for which the exact outcome of their support can be attributed to the donor and determined in advance. This ties the hands of aid recipient organisations. It takes away their ability to consult with their members in response to a local context always in flux.  It stops that process of empowerment that happens when individuals and organised groups are able to imagine their world differently and to realise that vision by tackling the injustices in their society”.

Crazy bake: the black dog of development?

Crazy Bake is a well-known NGO in Beijing, which seeks to improve the lives of patients living in a mental health facility. It is a program

“Involving the mentally ill at their facility just outside of Beijing. Crazy Bake’s goal is to improve the patients living conditions by giving the patients a meaningful task that is within their capabilities. The project was initiated by Yvonne Gerig and Natascha Prigge. In the past 3 years the project focused on a gardening project, crazy grow. Crazy Bake is an extension of the program designed to incorporate more patients and ultimately collect more funds for good use”.

The bakery is attached to the private hospital at which the patients stay. There is no psychotherapy or occupational therapy available for the patients. The expenses incurred by the patients, for food, housing, care, and medication is 800RMB (AUD$115) per month. Every patient (note: not beneficiary) receives a monthly ‘salary’ of 80RMB per month (AUD$0.37 per day). Sales amount to 1000RMB per week. Money is also raised through sponsorship and gifts-in-kind received in donation. Furthermore, according to the organisation, the patients are directly involved and in control of the decision-making process. They decide what to acquire with the sales profits at the hospital. Some notable acquisitions over the past few years:

  • Purchase of a karaoke machine
  • Purchase of a fridge for ice cream

You can learn more about the organisation in this MSNBC video spotlight.

Now, there are a few things to consider before we judge too harshly or otherwise. David Oaks, of Mindfreedom International, urges us to find more inclusive language than ‘mentally ill’. Crazy Bake’s website is littered with the phrase, and, in addition to the name ‘Crazy Bake’, does not support their mission to change perceptions of mental health in China. Despite this, the organisation is up against one heck of a wall in terms of mental health support in China. There is widespread discrimination and misunderstandings about mental health in China. It was only in 2001, that homosexuality was formally removed from the official Chinese Classification of Mental Disorders. “Traditionally, Chinese consider mental disease to be a shame,” and there is a fear of revealing issues to family and colleagues. In a society grounded in the cultural notion of ‘face’, this is of no surprise.

There is another way to approach this issue though, at it involves taking back previously inappropriate words (in much the same way that the African American community, people with disabilities, and women have done so) and hence, raising awareness of mental health issues in China. Through this lens, using the word “crazy” may raise awareness through its stark use:

“I feel words such as ‘crazy’ can actually be positive in certain contexts. Consider, ‘I’m crazy in love,’ or Apple’s early motto for their computers, ‘Insanely great.’ The word origin for crazy is ‘cracked,’ and in Japanese art the pottery with a beautiful imperfection has a special Wabi-Sabi value. On the other hand, a newspaper editorial or journalist disparaging certain citizens as ‘lunatics’ ought to be opposed” (David Oaks).

Of the health budget in China, which was 5.5% of GDP in 2009, only 2.35% of it goes towards mental health (although we should always proceed with caution when it comes to reported statistics, particularly budgetary, in China). This is in a country where reportedly 1 in every 13 suffer mental health problems.

“China has only about 14,000 qualified psychiatrists…about the same number as France, with 60 million people—compared to China’s 1.3 billion [...] Two million Chinese try to kill themselves annually…and China’s 750 or so state-run mental-health institutions can’t keep pace with the rising demand for their services” (from here, original article not found).

1 in 13 is about 100 million people. More alarmingly is the estimation that Chinese children account for 15-20% of children in the world with mental health problems. The mental health profession and services are still very much in their infancy. In 2005, there were only 572 institutions in the whole of China providing mental health services. That is only 1.4 beds per 10,000 people. The lack of services and support is further exacerbated in Chinese rural areas, where the majority (750 million) of the population lives.

It is an issue that I am only vaguely aware of, and one that I was completely oblivious to living here in Beijing. I may have even purchased some baked goods made by the Crazy Bakers without the slightest clue of its source. Mental health is not an issue that I am experienced or knowledgeable enough to address. Excuse the sports analogy, but if mental health were baseball, I would be the guy watching basketball. I can only highlight mental health as an issue that is rarely addressed, as far as I am aware (please speak up and correct me), in the mainstream aid and development community.

The stigma, discrimination and lack of inclusiveness is not just endemic to China. According to WHO, 450 million people globally are affected by mental health problems, which cause devastating and life-threatening human, social, and economic costs. Furthermore, there is a fear of losing ‘face’ not just in China, but across many different societies, albeit by a different name. According to one recent survey of attitudes towards mental health, 50% of those surveyed would be uncomfortable talking to their employers about a mental illness. Yet, if you were to take a sick day, it could likely be due to your mental health. According to Mind For Health, a UK-based advocacy group, mental health problems are responsible for an estimated 14% of the Global Burden of Disease (illness and deaths), but receive only 1% of world health expenditure.

Andrew Chambers, writing in the Guardian, calls mental health the invisible problem in international development. Researchers in 2003 found that of 191 countries studied, 32% did not have a specified budget for mental health. Furthermore, of the 89 countries which responded to the researcher’s questionnaires, 36% spent less than 1% of their total budget on mental health. Invisibility is further exacerbated by the lack of interest from NGOs, charities and the wider international community.Vikram Patel, Professor of International Mental Health at the London School of Hygiene & Tropical Medicine, writes that if/when mental health in Low- and Middle-Income Countries gets attention, new and innovative approaches need to be taken. The approaches to public health found in High-Income Countries cannot be replicated or reproduced.

What comes out of these readings and thinking on mental health in the development context are some questions worth thinking about and discussing:

  • Is suffering from an infectious disease, like TB, more important to individuals and to others than suffering from schizophrenia?
  • Can we place a value on different dimensions and indicators of health? Have we already? How do we do it?
  • Is there a perception that mental health is not a serious issue compared with say, education, income generation, etc.?
  • Is mental health considered a ‘valuable good’ by poor people? By you? Should it be?
  • Are investments in mental health cost-effective?
  • What role does stigma play in the lack of interest?
  • What would the social inclusion model offer in approaching mental health?

What ‘Crazy Bake’ shows, in working in such a highly stigmatised, invisible and underfunded area, is that actively including people in basic social and economic activities may not be such a crazy idea.