The Donor That Came in From the Cold?

One of the loveliest elements of having so many friends working on international issues is puzzling over the odd bits of the world in which we’re cathected, and tracing the ways in which we became so (an assignment, a particular story, a particular problem, a plane ticket purchased on a whim…). Those, for me, have been the conflagratory slices – Gaza + AfPak + Yemen (1 2 3 4) – for no good reason other than that I find the combination of dire humanitarian need and conflict-based constraints intellectually challenging.

Paul Collier, in opening The Bottom Billion, puts this aptly and succinctly:

“Traditionally, development has been assigned to aid agencies, which are low in almost every government’s pecking order. The U.S. Department of Defense is not going to take advice from that country’s Agency for International Development.”*

Continue reading “The Donor That Came in From the Cold?”

The Donor That Came in From the Cold?

Valar Morghulis

Introduction:
Game of Thrones, for those of you who are not familiar (I am really not; see disclaimer), is famous for high mortality rates that make viewers and readers very angry. As a global health graduate student (with a lot of free time at the moment…) I became interested in figuring out precisely how bloody this universe was, whether deaths varied by gender and status/occupation/affiliation, and how mortality in Westeros compares to mortality in low- and middle-income countries. The professor for a course I’m TAing in a few weeks also mentioned that he wanted an assignment on life tables, so, you know, I figured I should learn what they are.

No character names are used in this blog post, but I guess there might be spoilers if you can back-calculate in your head. Continue reading “Valar Morghulis”

Valar Morghulis

High Maintenance.

If you’re interested in international development and have not been living under a rock, you’ve probably stumbled across summaries and reviews of Nina Munk’s The Idealist (link to Mike Miesen’s excellent overview as I haven’t yet read it myself). In short, the book highlights the shortcomings of the Millennium Villages Project, conceived of and ceaselessly touted by activist and economist Jefferey Sachs. The project consists of comprehensive funding to the villages over ten (up from an original five) years, with the goal of ultimately providing a system by which holistic aid can eradicate extreme poverty.

As you might suspect, this approach has been flawed. Presidents scoff at the project while purchasing fighter jets; parts arrive, but are not installed; wells are built and run dry. Criticisms of the MVP point to the immense difficulty of building something different in a vacuum of physical and political infrastructure, in an environment that is simply not yet capable of sustaining isolated pockets of prosperity.

This book was published in November, prompting lots of interesting discussion on sustainability and wise investment. But since then, a few articles have highlighted similar struggles in implementation of development projects thousands of miles from sub-Saharan Africa.

After Billions in U.S. Investment, Afghan Roads are Falling Apart,” heralds the Washington Post. And of course they are; this follows an article in the same vein on hospitals by the same author, and the challenges are very similar. Step one: donors invest in basic infrastructure with the hope of promoting a cure-all. Step two: funders are surprised when projects that require maintenance and outside support falter after not receiving those things. Step three: we complain about poor spending and wasted tax dollars, shaking our heads at it all.

For some perspective, Texas and Afghanistan are roughly the same size at just over 250k square miles. The Texas Department of Transportation spent $3,767,263,875 on highway construction and repairs in 2013.  To be fair, those repairs would have been allocated to a more extensive road network (79,645 miles of highway in Texas versus 7,673 miles of paved road in Afghanistan), so let’s cut the amount by a factor of ten. The article notes that international donors have allocated $4 billion since 2001, so we’ll also multiply the Texas amount by 14 for a grand total of $5,274,169,432 – nearly 33% more.

This ignores the fact that many of Afghanistan’s roads are newly constructed, which is more expensive than maintenance, and that they’ve gone without repair all together. Lest you forget, Texas roads are also not targeted by roadside bombs, and we don’t hire security for our construction workers – a substantial portion of costs abroad.

I don’t mean to provide a judgment on the worth of this spending, and this analogy is not intended to be perfect. It is obviously a Colossal Problem that so many of the roads we’ve built over the past decade and a half years are worn away and pockmarked and shredded. But given the challenges of undertaking an infrastructure project of this scope, it seems like $4 billion might be quite the deal. There’s no way these roads were originally planned without the expectation that the Taliban would target them for destruction, and there’s no way anyone reasonably expected one of the least developed countries to manage maintenance on that scale. But I’m a little disheartened by the number of people who seemed to somehow expect the roads and hospitals we plop in Afghanistan to work while simultaneously deriding the MVP and similar short-lived development initiatives in SSA.

My point is that we should not have separate standards for development projects managed by traditional humanitarian donors and those run though defense agencies. If we expect development projects from NGOs to fail or falter when operating in a vacuum, we should expect the same – if not less – of those being implemented in conflict zones and by people who many not necessarily have strong training in development-specific challenges. As we watch the millennium villages backslide when Sachs & co. retreat to other projects, we should not be surprised when IED-induced highway craters go unrepaired as their former stewards withdraw. And if development practitioners have not yet figured out how to maintain infrastructure projects in impoverished places, I don’t see how it’s reasonable to hold the U.S. Army, with its very different mission, to a higher standard on those specific tasks.

Poor development planning and a short-sighted focus on one-off costs is bad behavior for both parties, but it offers much more dangerous consequences when backed with the full faith and credit of the U.S. military. It’s something many professionals in the home field haven’t figured out yet, and so it shouldn’t be surprising that nobody in the Army Corp of Engineers has either. Moving forward, these places need to hire out the very best sustainable development practitioners for consultation on the dirty work.

High Maintenance.

Infants, Infection, and Insurgency: Disease Burden in Afghanistan

For a general Western audience, mention of Afghanistan may bring to mind several narratives: domestic implications of endless war, wariness of radical Islam, images of burning poppy fields supplying the international drug trade. While these observations are grounded in some degree of fact, they largely reflect an extraordinarily poor society with significant barriers to development just beginning to rebuild. To put this in perspective: the average Afghan* woman will live to 52 years and will bear six or more children. The average male will support his family on an annual income of $584 USD, and will not see the age 50.

Of course, this sort of extreme poverty extends to health access. Of the different population- and disability-adjusted life year burdens measured by the Institute on Health Metrics and Evaluation, Afghanistan comes dead last – behind all other countries – in 19 of 50 categories.

Image
Relative comparison of the 15 countries with the highest disease burdens. That red ain’t a good thing (source: IHME).

At nearly 120 deaths per 1,000 live births, Afghanistan’s infant mortality rate is higher than that of any other country; in its especially remote regions, such as the Wakhan Corridor, an estimated 50% of children die before reaching the age of five. 34 years of constant war have wreaked havoc on health systems, skepticized a populace, and left mortality and morbidity burdens frozen in time, reflective of another era. Continue reading “Infants, Infection, and Insurgency: Disease Burden in Afghanistan”

Infants, Infection, and Insurgency: Disease Burden in Afghanistan