Spare change

Arvind Iyer, one of the most intellectual personalities I have had the fortune to call my friend, sent me this link echoing the question asked at the very end of the video (which you must watch), “How can anyone fail to want to help these people?” For those of you spoiled by executive summaries, I’ll indulge you and give you a gist of what the organization 50pence.org seeks to do. Their contention is that with just 50 pence (75 cents), you can buy a person treatment from six debilitating or fatal diseases for one whole year. What person, except for the sado-psychotic, would not offer their money for a cause as ridiculously important as saving a life? Yet, we all do it routinely. All of us hold on to our purse strings and those 50 pence never really reach the people to whom it means so much more. It’s plain that our miniscule donation could save a life, and yet, we fail to make that donation. What gives?

The answer lies in a thought exercise that I encountered as a graduate student at Harvard. During a lecture on ethics by the exceptional Daniel Wikler, he told us to imagine a scenario. This is what he said, “Imagine there’s a button on the wall. Every time you press it, a life somewhere is saved. Every single time. Will you press it once?” A couple of bewildered looks later – this was the school of Public Health, after all – there was general agreement that the button would be pressed once. “Would you press it twice?” Dr. Wikler countered. “Of course”, we all yelled. “How about 10 times?” “Definitely.” “A hundred times?” “Bring it on!” “Ten thousand times?” After the slightest hesitation, “Why not?” Then, he said, “How about the whole day? No bathroom breaks, no breaks for lunch, no breaks for sleep. Nothing.” We now knew where this was going; and we didn’t like it. I mean, what do you do when nature calls?! He didn’t leave us thinking too long. “How about for the rest of your life, you keep pressing that button?” Of course, the question was a rhetorical one, but its power was not lost on any one of us. Here we were, eager public health professionals, having dedicated our entire existences to saving lives through the world by any means possible. Here we were, and when we were offered something as simple as a button to save lives, we were reluctant to use that facility for the rest of our lives. Gosh, we balked at committing ourselves to it for even a full day.
Essentially, the matter comes down to how we think at the margin. After the ten thousandth button-press, do we think of the ten thousand lives that we have saved? Or do we think of the one life that we could save by pressing it one more time? And then another, and another, until one reach six billion presses. It really does boggle the mind, and honestly, I do not know how I will react if I were to find the fabled button-on-the-wall.

Pressing that button on the wall is akin to donating 50 pence to deliver the life-saving treatments to those who need it most. In essence, every 50p donation is a button-press. If you plan on buying this BMW, you could as well have used the money to help 84,000 people for one year. My education at Harvard could have in fact bought services for 50,500 lives. The money spent on the opening ceremony at the Commonwealth Games in India one week ago would have brought the services to 42.5 million people. The math is staggering. Critics will argue and accuse me of being the cynic who knows the price of everything and the value of nothing. Admittedly, the above analysis is an oversimplification of much more complex economic forces that are at play in such calculations. Nevertheless, I believe it’s something to think about.

In the final scenes of Steven Spielberg’s “Schindler’s List”, Oskar Schindler, who uses his entire fortune to buy the lives of Jews who would have otherwise been executed at Nazi concentration camps, brings this entire conundrum to poignant, dramatic prominence. “Why did I keep this car?” he says, “it could have bought us 25 more lives…and this golden ring, it could have bought us 4 more lives.” That’s a dilemma to which I don’t pretend to have an answer. All I know, is that 50pence.org will continue to do the good work they do, while always being short of funds to save that one extra life. In the meanwhile, we shall enjoy our Lamborghinis.

Note 1: At the rate of 100 button-presses a minute, it would take 115 person-hours to save 6 billion lives; essentially, two life-times. If I find the button, will you find two volunteers?

Note 2: The author, sadly, does not drive a Lamborghini.

Take the "Cash" out of Conditional Cash Transfers

It takes a lot to get people to change. Then God said, “Let there be Conditional Cash Transfers”; and He saw that it was good.

Often touted as the magic bullet in the development community, conditional cash transfers, or CCTs as they shall be hence known, hold immense promise. They have increased the rates of institutional deliveries, put thousands of children into school, and helped many more crawl out of poverty. The introduction of CCTs has brought a paradigm change in the arena of behavior modification.

For the uninitiated (Hi, Ma!), a CCT, as the World Bank defines it, is a program that transfers cash, generally to poor households, on the condition that those households make pre-specified investments in the human capital of their children. CCTs have now exploded across the world and although the jury on whether they are an acceptable intervention in any situation where a behavioral modification is required, they have proved their effectiveness and efficiency in a number of settings and cultures. Money, it turns out, does make the world go round.

My question is, can’t we use something else to turn the world round? I’m sure cash in hand is a powerful incentive in modifying behavior, but the cash itself has suspect usefulness from a development perspective. For example, what’s to stop a man from using the money he received for sending his kid to school, to buy himself a week’s supply of liquor? There are conditions on the receipt of the money, not on the use of that money. Wouldn’t it be better to construct a system where the incentive for healthy behavior is itself health-promoting? The two-birds-with-one-stone deal. Vestergaard-Frandsen has an answer.

Vestergaard-Frandsen is an interesting company that runs what they call a “Humanitarian Entrepreneurship” business model. It is essentially a social enterprise that follows a “profit with a purpose” approach. They develop products that cater to the health needs of the developing world, price them competitively and make their profit from the whole exercise. They have a whole array of products ranging from portable water filters to mosquito nets. Recently, they embarked upon an experiment that put their money where their mouths were.

Instead of describing the details of their experiment for you, I’d rather direct you to this excellent description by their communications and public relations director, Peter Cleary. If you have a little more time, I highly recommend watching this video documenting their work. For the truly lazy, and strapped for time, here’s an executive summary. The good people from VF went out to a district in Kenya, and gave out - for free - a combined package consisting of a bed net, a water filter and condoms. The only catch- they had to receive counseling for an HIV-test. Before you scream “Unethical!”, you should know that the actual test was voluntary; all that people had to do to “earn” the package was undergo counseling about the test. In the span of one week, they succeeded in testing 50,000 people, a massive upsurge in voluntary HIV-surveillance, in a community that was traditionally loathe to get itself tested for HIV. The incentive inducing people to get the HIV-test wasn’t any cash; it was the CarePack, VF’s name for their goody-bag. It worked perfectly.

The philosophy behind this experiment takes the interpretation of integration to a whole new level. Not only does it integrate effective interventions for the three most devastating diseases in the region, HIV, malaria and diarrheal diseases, but it also integrates the private sector, government machinery and most importantly, the community. They brought on Yvonne Chaka Chaka, a South African singer, who is also a local superstar, and incorporated her into their advocacy strategy, which drew people out of their homes and into the testing clinics. This was the kind of community involvement that money cannot buy.

This brings me back to my original argument, that CCTs may be innovative and imaginative, but they don’t go the whole way. There may just be a much more cost-effective and in truth, useful, way to incentivize people. The folks at Vestergaard-Frandsen certainly have a story to prove so.

Don't forget the men

The UN Secretary-General’s new strategy to achieve the MDGs incorporates a truth that has been well-documented for the longest time now- that subsidies and benefits focused on women and girls have a multiplier effect that positively ripples throughout the family, community and society in which the point beneficiaries reside. Personally, I endorse this vision and more than a value judgment, the above notion has proved itself to be a verifiable fact. One of the strongest examples that come to my mind is the principle that Muhammad Yunus’ Grameen Bank followed in its micro-lending model: target the women, and you will get maximum bang for your buck. There can be no stronger empirical argument than the success that Grameen has had over the decades in alleviating poverty. So, by all means, you must know where my sympathies lie.

However, there is a caveat that’s worth issuing at this point of time: Don’t forget the men. True, programs targeting women beneficiaries yield maximum social benefit. True, the empowerment of women is the greatest social mobilizer that one can imagine at this moment. True, the hand that rocks the cradle rules the world. However, beyond these truths and adages, there lies a more fundamental reality, the reality that all societies in the world, except for the most enlightened, follow patriarchal systems. The wielders of power in most parts are men, and if we leave them out of the development equation, we risk unacceptable failure. The empowerment of women should be our goal; but the keys to that empowerment lie with their male counterparts.

With the new UN strategy, there is the risk of the development fraternity (if you’ll pardon the usage of the term) launching into an all-out offensive, keeping women and girls on the frontier. This would mean programs targeting women in their marketing campaigns, distributing subsidies and benefits only to women and portraying women as the most important piece in the MDG puzzle. I call this a risk, because one chances the alienation of the other party on the chromosomal divide- the men. Men are still the major decision-makers in most households, and a purely woman-centric strategy would not lead us anywhere. We need to target men as forcefully as we target women. The message doesn’t change much. We still put out the headline that women are the central piece of our development strategy, but men are our esteemed guests as well. You may accuse me of mollycoddling the male ego, but the truth is, the inflated male ego is a practical reality.

Done with the rhetoric and theory, I’d like to offer you a real example of how this works. While I worked on the field in Talasari, India, the program that I was a part of was sought to improve maternal and child health. The largest component of our activity was community-level advocacy and behavioral modification. The first couple of months provided frustrations. The adolescent women and pregnant mothers we spoke to nodded their heads in agreement, but we repeatedly saw them relapse into their old, dangerous practices surrounding pregnancy, childbirth and child-rearing. I had my Eureka moment at one such session, educating mothers huddled together in a small little hut that was the home of one of the women. Her husband, who wasn’t feeling too well, hadn’t left to plough his land that day, and stayed home. As I talked to the women, this young man who could hardly be older than me, listened in rapt attention to what I was saying. The most surprising part was when he asked me questions about the information that I was doling out that morning. I went back to our Center with an idea. Why not bring husbands into the equation as well? They were, after all, the decision-makers.

What followed was a year of male participation in our program. The director of the program and I created a system where we would speak to the pregnant woman and her husband, as a couple, and bring them to buy the idea that it wasn’t her that was pregnant, but that it was them who were pregnant. Again, to my surprise, this was an idea readily acceptable to the men, and almost immediately we saw improvements in our compliance rates. It turns out, that all we needed was to convey to the men what their wives needed to be doing, and the changes happened.

I’d like to issue a caveat to my caveat. The ultimate endpoint is to have a situation where women follow healthy practices, without needing the permission or nagging (yeah, right!) of their husbands. The ultimate goal is to have a society where each woman is empowered enough to take her own decisions, and informed enough to make sure that those are the right decisions. However, till we reach that goal, let’s keep the men in the game as well. We aren’t all that bad, you know.

It wasn't me!

I love the word accountability. I love how it conveys such gravitas, being packed with so many syllables and all, and yet is a rather loosely used term with rather indefinable borders. Case in point- accountability in the world of development.
At a side-event during the UN MDG Summit, one highly passionate gentleman stood up and launched into a diatribe on what he called the hypocrisy of the donor countries. He was livid that donor countries routinely blame partner countries for not being accountable to the commitments that were made, when, in fact, the donor countries themselves don’t live up to their own aid commitments. While the man had a point, I grew more interested in the whole idea of accountability. It got me thinking about what accountability really means.

At the micro-level, it’s pretty simple. When in school, you’re accountable for your grades, and you’re accountable to your parents. If your grade slips, so do your evening privileges. When you grow up and get a job, you’re accountable to your boss. If you don’t get the job done, it’s the door for you. Plain as cheese. Everything about micro-level accountability makes sense to us. However, things start to get a lot more nebulous when you reach accountability at the national level. For example, is Barack Obama responsible for the financial mess that the US is in? Or should the blame be appended to George Bush? Or does the malaise go all the way back to Reagan? Or would the current crisis had happened irrespective of who was pushing papers in the Oval Office? Where does the buck really stop? One thing is certain though; whom these presidents are accountable to- their people, the American people, who get the opportunity to keep their leaders honest, at least come election season. Alas, in global health and development, even this facility is lost.

Essentially, there are three stakeholders in the world of global development. There are the donors, who hold the money; the partner (or recipient countries, as the politically incorrect would call them), who need the money, and the delivery agencies, who spend the money. Several times a year, these three groups come together and declare their need to fulfill the commitments that have been made in the past. There is acceptance on the part of the donor countries that more aid needs to be given; there is acceptance by the partner countries that they need to allocate more resources to health and that they aren’t doing enough; and there is acceptance by the delivery organizations that the aid needs to be more effectively and efficiently used. What’s important, though, is to understand how these groups or actors interpret their responsibilities once they take their flights back home.

Each donor country has the best of intentions at heart. I’m sure that when the commitments are made, each intends to honor that commitment. However, fiscal realities are fiscal realities. In the event of financial hard times, of the kind that we are seeing at the moment, there is no mechanism in place to ensure that the donor governments stay true to their commitments. The only entity a donor government is really accountable to is its own electorate. As far as I remember, no election has ever been lost because the government did not honor their international commitments. In fact, the overwhelming incentive is for the government to renege on their international commitments, and instead divert those resources toward their own people which would, no doubt, yield greater electoral success. It’s no surprise then, that international donor commitments have not been fulfilled. If anything, I’m surprised that the donors have actually put as much money out there as they have.

This is all the more surprising when you consider the negative reinforcement that they have been subjected to by the other parties at the negotiating table. The partner countries have hardly lived up to their own commitments. The Abuja Declaration which committed African nations to allocate 15% of their national budgets to health has been implemented by fewer countries than one would like to admit. This is only one of a series of failed promises that partner countries have made to the international community. Yet, in the true sense of the term, partner countries are hardly accountable to their people on their commitments to the international community. Of course, the fulfillment of these commitments would make for, in theory, a more favorable result for the incumbent government in elections; but how many developing countries actually function as vibrant democracies? Too often, governments in developing countries are elected to power not based on their ability to govern effectively, but by the strength of their clan or religious affiliations. No partner government fears being toppled because they didn’t honor international commitments.

Finally, we arrive at the plate of the delivery organizations. These are the entities that spend the money that the donor organizations put into the basket. It includes the policy think-tanks and the implementation bodies. The billions of dollars that makes the world of international development go round passes through their hands. They determine the agendas, design the policies and implement the programs. In effect, they are the ones responsible for ensuring that the aid money is used most effectively and takes the world towards the MDGs. With the dismal performance on a number of the MDGs, it’s evident that we, the “middle” organizations haven’t been doing our job very well. In a corporate setting, heads would have been rolling all over the place; and yet, we haven’t been held accountable to our role in this entire machinery of world-changing significance. In his speech to the UN General Assembly, President Obama said that the international community cannot continue doing things the old way; and, yet, I fear that is how it’s going to be.

It’s going to be that way because our collective accountability is to the weakest stakeholder of all. Our collective accountability is to the 7 year old girl who has no access to education or any form of empowerment. Our accountability is to the pregnant woman who contracted HIV from an abusive male partner. Our accountability is to the poor man who has too much malaria and hunger to worry about global commitments. Our prime stakeholders cannot speak for themselves. They are not in a position to hold us accountable, and perhaps that’s the reason why we, as an international community, take our commitments less seriously than we ought to. Our commitments must be real, they must be enforceable, and our accountability must be tangible and incentive-driven. Much can be suggested about how this can be done. Rather than expounding on those in this post, I’d rather lead you to look at it from another perspective, the perspective that tells us that we are accountable to future generations. The people of the world to come will look back at us and judge us by our performance, and for us to know how we will be judged, we have some wise words from Mahatma Gandhi, “The greatness of a society can be measured by how it treats its weakest and most vulnerable.”

Not Charity, but Solidarity

I was at a party last week that capped a hectic, but thoroughly fascinating week at the UN MDG Summit. The party was actually a happy-hours MDG gig organized by a forum cheekily called BYOC, or Bring Your Own Cause. After a week of hobnobbing with the who’s who of global health and development (I met Margaret Chan, Director-General of WHO thrice!), this party was a refreshing off-off-UN Plaza affair. Nobody talked about advocacy, nobody uttered ‘leveraged partnerships’ and most importantly, nobody said anything about ‘new money’. It was all very laidback with most people younger than me, bringing with them the youthful enthusiasm that somehow gets diluted the closer one gets to UN Plaza.

Sometime during the evening, I got drawn into conversation with a hulk of a human being. He was German, of course, and standing at well over 6 feet, he literally towered over me. I recall him telling me that he was studying International Affairs, and our conversation drifted to social systems as he was keen to know about the caste system of which India is the unfortunate heir. He then proffered that the class system in Germany wasn’t very much different than the caste system, and it was difficult, if not impossible to rise above the class that you were born into. Of course, I would argue that in India, one gets bogged down by the double whammy of the caste AND class system, but I was intrigued to know that social mobility was a deep concern even in a society as advanced in Western values of individualism and freedom as Germany. My German friend then made an interesting argument, which I thought held its fair share of water. He said that social mobility was difficult because the folks at the top of the pyramid were afraid of relinquishing their top-dog position to those from lower levels. Continuing with the argument, he said that those at the top are all too happy to share their resources with the ones below, as long as their positions are not challenged. When they fear for their own supremacy, their generosity dries up, and they become protectionist and would do all within their power to hold on to the reins of power. Legitimate logic, I thought. He then extrapolated this pattern to international aid. He predicts that with the rise of the Asian powers of India and China, traditional donor countries like the US and Europe would be wary of helping these countries in their ascent and international aid flows would see a precipitous decline. I have to say, I could find no fallacy in his argument, and it sounded pretty convincing at the time.

However, my doubts about continued international aid were soon put to rest by President Obama’s address to the UN General Assembly. They were further allayed as I read through the US Global Development Policy, the first of its kind issued by a US President. It was quite a relief to see that the most powerful man in the world does not view international power politics as a zero-sum game. The Obama administration realizes that there is place for all nations in the evolving global geopolitical landscape, and doesn’t necessarily view the world as a hierarchy, but rather as a comity of nations whose collective prosperity would always surpass the wealth that any one nation could generate for its citizens, acting independently. You may claim that I’m naïve to believe the politically correct posturing of an astute politician, and I realize the validity of that claim. For all we know, perhaps the developed countries may take on a stance of protectionism to hold on to their positions at the top of the ladder in the years to come. That, however, would be their own undoing. The unprecedented prosperity that the developed nations have seen over the last century or so is the result of them allowing each market to feed off the prosperity of the other, thus leading to a hyper-functional system where the whole is more than the sum of its parts. If Adam Smith taught us anything, it’s that an economically formidable partner is more of an asset than a threat. In his speech to the General Assembly, President Obama pointedly asserted that the aid that was being given to the South isn’t really an act of charity, but rather, an act of self-interest. That one line tells me, more than anything, that Obama gets Adam Smith, and is a far cry from the socialist that he is so often accused of being, and that I wish he was. At least, he seems to be the good kind of free-market advocate.

My guess is that seeing developing countries actually developing, the rich nations will drool at the prospect of growing markets for their products thanks to increasing purchasing power, and that will spur them to push the process along even more quickly. So, Holger, rest assured that international aid will not dry up. If anything, it will further increase, continuing the trend that recent years have seen. Your job and mine are secure as long as a market remains to be created; and that shall remain a prospect till kingdom come.

Like Money in the Bank

One of the more interesting, and even, in my eyes, ridiculous events at the MDG Summit last week was a session that was deceptively titled “Innovative Financing for Development”. Always keen to hear about where the fabled “new money” for development would come from, I made it a point to attend this event, in the hope that I could tap into the most radical thinking in terms of generating funds for development. I got to hear radical thoughts, for sure, but of a slightly different nature.

What was touted as a session Innovative Financing turned out to be deliberations (which I felt were self-aggrandizing) on a proposed Currency Transaction Tax. That was it. No talk about the International Finance Facility for Immunization, no talk about optimization of the funds available through the Global Health Initiative. Nothing. Innovative Financing to these folks was levying a Currency Transaction Tax (CTT) on all international currency transactions.

To be fair, I have to acknowledge the promise in the idea. International currency flows at mind-boggling volumes from one location to another. In 2010, this volume has swollen to USD 4 trillion a day. Yes, that’s 4 trillion A DAY. The estimate is that a taxation of barely 0.005% on this amount would yield a sum of USD 33 billion a year, which would then be channeled into development efforts throughout the world. I have to hand it to the fairness of the idea of a tax on currency flows that until today have largely been unaccountable to international regulation. The argument continues to state that a proportion as small as 0.005% will have no noticeable effect on the volume of these transactions, which does seem reasonable. Finally, of course, the world of development could do with 33 billion dollars of spare cash.
Now, for the critique. What I found most disturbing at the discussions were the attitudes the panelists and indeed the members of the audience had towards the whole idea. There was such a strong sense of self-righteousness and entitlement that one would have imagined the money that the CTT would yield was something that they themselves had worked hard for. I watched in astonishment as each panelist proceeded to rail against the banking system and the entire financial establishment. They brandished their pitchforks and torches to ferret out the immoral and “criminally obscene” profits that the financial world was making. It’s time “they did their bit” to help an ailing world.

Now, I’m certainly not a Wall Street sympathizer, but there were several things wrong in the approach of the panelists and the audience that day. First, they must realize that they are demanding a pound of flesh from none other than the richest people on the planet outside of Hollywood. These guys got rich not by being conscientious, or socially aware, but rather with their eye on the bottomline. It would be foolhardy to believe that moralistic patronizing would carry water with an organization as far down the road to perdition as Goldman-Sachs. A different approach is required.

My second issue is political. The talk that morning portrayed bankers as monsters capable of no good whatsoever. In talking of the bankers as “the bad guys”, you are immediately making enemies of them, and they are a poor choice of foes. If money makes the world go round, the folks in the banking sector have it spinning like a crazy top. These are powerful people, with powerful friends. If you try to push a tax through without having them on board, you will fail. You will lose a confrontation; so don’t even attempt it. There is another way.

When President Obama was still Candidate Obama, most people on Wall Street knew he would lean further on the left. They knew he’d tax them, and that they’d earn less if he was elected; and yet, Wall Street voted for him, with both hands. Incongruent, you think? Not so, say I. Contrary to how we typically portray them, bankers are not ogres, with greenbacks for irises. They are human beings, and feel the entire range of human emotions, greed being only one of them. They know when a need exists, and they know when they are being called upon to contribute to the health of society as a whole. This is the asset we have, that each one of them is human, and hence, vulnerable to the humanistic agenda we preach. However, we can sell this agenda to them only as long as we have them on our side. The minute we push them away, we lose their sympathy, and more importantly, we lose their money. If we treat them as partners and equals, they would come to the table of discussion and the CTT may yet be passed. All we need to do is convince them. In order to do this, we need to prove to them the legitimacy of our cause. Alas, it is at this point that my third and biggest concern lies.

My final concern is the moral prerogative we have, as the development community, to ask Wall Street to make sacrifices and do its bit. Most of the events around the Summit happened in the most deluxe hotels, and served the finest food and alcohol. Maybe this is just me, and it’s unfortunate if it is, but we do not present the image of being a community with a scarcity of resources. If we need any sort of moral legitimacy in asking the financial world to contribute its share, we need to show some austerity in our own gatherings. I would find it extremely hard to say to somebody in Morgan Stanley that I’d like some of his money – for free – so that I can throw a party for my friends at the Helmsley Hotel. Yet, this is exactly what we seem to be doing. A banker making his way from Wall Street to 3 UN Plaza will hardly be able to see any distinction in the excesses.

Love thy neighbor as, well, thy neighbor

Much has been written and lamented about the failure of the international community to cough up the resources needed to come to Pakistan's aid in order to help with the flood relief effort. India, being a neighbor has been expected to contribute to the relief effort, and in our enthusiasm to be of aid to our whimsical neighbor, India has offered to route the relief material it sends across through the UN, instead of the logistically more appropriate bilateral support we could offer. This, of course, is a reaction to the Pakistani reluctance to be seen as taking aid from arch-enemy India. Oh, the ignominy, Pakistan! Of course, every humanitarian bone in my body screams, gush forth with all you have, India. However, having studied health policy at no less than the Harvard School of Public Health (yes, this blog may one day double up as my CV), I can think of a more devious, and hence, better strategy that India may pursue.

The war India fights in Kashmir is not a war of choice. It's a war foisted upon her by mischievous elements outside of our borders. Once an externally propelled war, it has now grown to be an externally supported war, with the secessionist movement in Kashmir having taken an alarmingly local character. Of course, the ISI is always seen to lord over all that things militant in Kashmir, and for good reason, but the breakout of violence, and the brazen rejections of Indian calls for dialogue by some leaders of the Kashmiri people only indicate that India only holds Kashmir militarily. The people of Kashmir increasingly view India as an oppressor and an occupying force. India is losing the battle for the soul of Kashmir.

Floods, hundreds of miles away, could change things. India has the economic and logistic clout to be able to be of immensely greater assistance to the people affected by the floods than the insipid Pakistani government ever could. India should ask for its pound of flesh, though. And my proposed pound of flesh won't leave the Pakistani people with a hole in their gut.

India should insist that the aid that is delivered to Pakistan is called what it is- Aid from India. I always appreciate the tag-line of USAID-A gift from the American people. Let the 5 million dollars of aid that India offers to Pakistan be called that- a gift from the Indian people. If we're indeed calling it that, I would suggest, let's give much more than that to Pakistan. In fact, let's pay for this entire relief operation. Let's go in and fill the void that the Pakistani government has failed to do. Before you accuse me of blind brotherhood, let me assert that my suggestion is rooted in explicit self-interest.

India spends the equivalent of more than 20 billion dollars on defense activities. Of course, most of this expenditure goes into thwarting the threat of cross-border terrorism perpetrated quite admittedly, by Pakistan. There are elements within Pakistan whose existence is merely to perpetuate the bad-India story. This is the story that wins them recruits to their cause of cross-border and even global terrorism. Imagine what it would do for their PR campaign if the food cans their recruits ate out of said "A gift from the people of India". I'm not saying it will work for sure, but the next time an Ajmal Kasab has to pull a trigger, he'll know he won't be firing at an oppressive ogre, but somebody who helped put baked beans on his plate during a bleak time. And that may just make the difference.

The right thing for India to do now is to help Pakistan, in whatever way we can. However, making our contribution anonymous would be a strategic mistake in the name of self-sacrifice. Instead, India should stand up and be counted. India should tell the Pakistani people that when they were at their weakest, the Indian people came to their aid. That will save many more Indian lives than it does Pakistani.

Blind Data

“In God we trust. Everybody else must bring data.”- NR Narayana Murthy, Chief Mentor, Infosys Technologies

The stand-out session for me at the recently concluded MDG summit was the one organized by the World Bank and titled, “Impact Evaluation”. The panel included Michael Kremer, Gates professor at Harvard University, who was literally the only person from academia that I met during the entire week at the Summit. The rest of the panel included folks from the World Bank, and was chaired by the very impressive Michael Anderson, Director-General of Policy and International Relations at DFID. The subject of discussion- data, and how it drives policies today.

Each expert presented a point of view from their respective fields of interest. The central theme was the relevance and importance of generating data to drive policy, rather than assumptions and “common sense”. Of course, after one year at Harvard, this manner of thinking wasn’t new to me. There is such a strong emphasis on data that one may be forgiven for the RCTs-for-parachutes jibe that has become part of the lore of research humor. Sitting back, though, it’s quite incredible how radically different this manner of thinking is to me, compared to what I was exposed to in medical school.

India isn’t really the hotbed of research. For all our prowess in math, and chauvinistic claims of having gifted the world the concept of zero, the sad fact is that, as a people, we do not think in terms of numbers. This, however, I have learned, is not a problem restricted to India, or even the subcontinent. It is a problem in Africa, a problem in South America, and definitely a problem in Asia. In fact, it might be interesting to study the relationship between per capita income and the reliance on data in determining policy within a country. My guess is that there will indeed be a correlation, although I’m not so sure about which would be the chicken and which would be the egg.

In the clinical world, the practice of eminence-based medicine rather than evidence-based medicine is the pejorative phrase that’s used to describe the philosophy of “I’m the boss, and I told you so” in designing patient care. Protocols and standard guidelines get thrown out the window while the heuristic practice of policy replaces them. Policy-makers and decision-takers routinely make their choices based on their personal experiences, irrespective of what the published literature suggests. This gives rise to statements like, “In my experience, this works.” Of course, the fallacy of their sample size of one could be pointed out to them, but for somebody with less training in statistical methods than a 3 year old, the argument would be a lost cause.

It’s time this changed. It’s time students were taught to start thinking in terms of numbers and hard evidence. I’ve previously blogged about my attempts to rectify the anomaly by setting up IMPULSE. The enthusiasm of the uptake of this effective intervention shows great promise for replication on a larger-scale, and as a community, the development world would do very well to sell the idea to schools and colleges in the developing world. This would enable us to develop the in-country expertise of generating data required to formulate sound policy, without having to resort to the expert advice of expensive consultants. Indeed, local capacity building is the most effective means of cost-cutting in international development.

Data is the final leveler. Whether you conduct your research in the finest labs of Harvard, or in the most trying circumstances on the field, in India, as long as your data and methodology is sound, you have the upper hand. It’s very encouraging that the world has now started to think robustly in terms of using data as the prime determinant of policy. The chair of the World Bank panel remarked with satisfaction that he was surprised that not a single member of his audience stood up, and claimed that data should be second to on-field experience in determining policy, as he expected. Mr. Director-General, I believe our trends are promising, but your sample was skewed. New York City is a world away from the chaos that is Mumbai. You should know; you work in New Delhi.

Superstar advocacy

The Global Health Initiative lists the centrality of women and girls in its agenda as one of its guiding principles. President Obama and Secretary Hillary Clinton have repeatedly asserted that an important focus should be placed on the rights on women. The recently concluded MDG Summit talked expansively about the need to put the rights of women and girls at the center of the development agenda. All of these are the right noises. Yet, I believe, these noises are being made in places that are so high up in the stratosphere that they fail to impact the very people for whom these noises are made- the girl in India, the pregnant woman in South Africa. The noises that people are hearing there are, in fact, very disturbing.

I had the opportunity-if one may call it that- to watch the Bollywood film Dabbang, starring Salman Khan. For those who don’t know Salman Khan (which planet have you been hiding on?), he is arguably the biggest, most bankable star in the Indian movie industry. His legions of fans and the instant recognition and credibility he brings to his films make him an important person in the cultural landscape of India. His film Dabbang broke box office records, and it portrays him as a police officer fighting against a corrupt system, while somehow mired in it (Bollywood logic, don’t look at me!). During the course of his exploits – and there are many – he settles his desires on a stereotypical village girl, complete with the beautiful face, deferential attitude and abusive father. He, of course, has to rescue her from the misery that is her life. But first, he has to win her heart. He does so by literally eve-teasing her and harassing her to the extent that he gets her to come to the police station by leveling false charges against her drunken father. Of course, the film does this to try to be funny, although I hardly laughed. My complaint, however, isn’t against bad cinema; it’s against how this film – and others – depict women.

Primarily, it shows the woman as somebody to be saved, somebody who does not have the power or control over her own life that she needs a man to come out and rescue her. While this may reflect reality in many Indian homes where women are afraid to stand up for their rights, all the film does is perpetuate this cycle of oppression. More disturbing though, is Salman’s methods to woo his woman. Salman is a role model to many in India; people look up to him and imitate his mannerisms and actions. His celebrity burdens him with great responsibility. An impressionable youth sitting in a cinema house in India watches Dabbang, and thinks, “I want to be just like him. If Salman harasses a girl he likes, it can’t be wrong. Maybe I should try that on the ‘object’ of my fancy too.” The outcome is all too apparent to somebody who has lived for an extended period of time in India, especially in the unruly north. The worst part is, this phenomenon of legitimizing the suppression of women’s right to a decent life isn’t limited to Dabbang. I remember having been disturbed over and over by Bollywood with so many of the films I’ve seen. The objectification and demeaning of women is simply disgusting.

No matter how many syllables the international community packs into words like advocacy, the sad fact is that, on the ground, those who should be the real advocates of women’s rights, are exactly the opposite- the purveyors of a bankrupt culture that puts women in second place. Whether this is in India, or in South Africa, where the polygamist President Jacob Zuma gets away with rape by claiming that his culture demanded that he should not leave an aroused woman “unsatisfied”, the noises on the ground are all the wrong ones. No matter how many meeting are held at the UN Plaza, and no matter how loudly Bono croons, people’s and partner government’s attitudes will remain calcified unless the thought leaders within local communities and cultures show a sensitivity and maturity in dealing with these issues which are so important to the agenda of the MDGs. After all, this is a battle of sensitivities. The transgressions in Dabbang, I would proffer, seem to be the outcome of the absence of somebody sitting with a sanitizing brush and making sure that the film isn’t socially harmful. Salman Khan, I believe, is an earnest man, and the film is honest in its intentions. After all, in one fleeting scene, Salman Khan makes a very obvious reference to the pulse polio campaign in India, and the importance of vaccinating children. The development community clearly has an ally in Salman Khan. We now need to align him with each of our agendas. Advocacy couldn’t be nearly as useful at the Millennium Plaza Hotel as it could be at the office of Salman Khan, Bollywood superstar extraordinaire.