Andrea Schapper

schapper@bigsss@uni-bremen.de

Andrea Schapper is a PhD Fellow at the Bremen International Graduate School of Social Sciences in Germany and is currently a visiting student at the Graduate School for Asian Studies at Cornell University in Ithaca, New York, USA. For her dissertation project, she has conducted three months of field research in Bangladesh and India. Before taking up her PhD research, she worked as an International Consultant for the International Labour Organization at their headquarters in Geneva, Switzerland.

Scholarly Abstract

The Government of Bangladesh has ratified the UN Convention on the Rights of the Child and the ILO Worst Forms of Child Labor Convention. Although national legislation pertaining to children’s rights is inconsistent and the National Child Labor Policy has yet to be adopted, many activities to transport children’s rights principles to underprivileged children have already been initiated in Bangladesh. These mainly take the form of projects by International Organizations or the Bangladesh Government, implemented through local Non-Governmental Organizations or local government structures. Two programs are introduced here, the rural “Food for Education” Program and the urban project, “Prevention and Elimination of Selected Worst Forms of Child Labour in the Informal Economy in Dhaka City”. Both are analyzed in terms of what mechanisms and actor constellations were used to promote children’s rights at the grassroots level. Even though these projects reflect the principles of global norms and transport them to the local people, reaching out to a high number of underprivileged and poor children remains a challenge.

Author’s Note

During my work as a Carlo-Schmid-Scholar at the International Labour Organization, I conducted research on projects that aim to increase school enrolment and attendance, reduce dropout rates, and eliminate child labor. After reading quantitative evaluation reports, I wondered if these programs indeed reflect the principles of international legal instruments. Additionally, I asked myself if these activities are actually necessary after national governments have already committed themselves to guarantee these rights. I also wondered why, despite increasing ratification rates, human rights situations do not necessarily improve. Against this background I decided to create a qualitative research project that systematically traces the process of international human rights gaining meaning among its local addressees. This resulted in a dissertation project on children’s rights implementation with a larger case study involving field research in Bangladesh.

Keywords: children’s rights, child labor, education, Bangladesh.

From the Global to the Local: How International Children’s Rights in Bangladesh Reach the Grassroots Level

Introduction

Inspired by Mary Robinson, the former United Nations High Commissioner of Human Rights, who was convinced that if human rights doesn’t have meaning locally, it has little meaning elsewhere, I started my dissertation project eager to find out how global human rights norms can reach the local level. I was particularly interested in the steps that need to be taken after the ratification of legal human rights instruments, and I wondered what mechanisms and actors have to be in place to make these rights meaningful to the local people. I chose Bangladesh as a case study because after the ratification process of international children’s rights and the adoption of national legislation and policies, many activities were initiated there to actually transport principles of these rights to the grassroots level. In other words, children’s rights implementation in Bangladesh constitutes a data rich case. The two most important principles in global child rights are 1) the right to education and the right to health, as anchored in the Convention on the Rights of the Child; and 2) protection from economic exploitation and hazardous work as codified in the ILO Worst Forms of Child Labour Convention. Considering the Bangladesh context, there are two compelling questions. First, how do principles of international conventions reach the 3.179 million child laborers, 40.6 percent of whom are engaged in hazardous work? Second, can education be provided to working children, 41.3% of whom are illiterate?

Economically active children (ages 5 to 17), child labor, and hazardous work by gender in millions (current status)

May-July 2008; Dhaka, Bangladesh; Child laborers in an urban slum making bracelets to sell. This dark, sticky room without proper equipment constitutes a hazardous working environment. The children, many of whom are below the legal age for employment, must cower on the cold stone floor.

To address these two questions, I examined projects that reach out to local children. These projects are complex and multilayered, ranging from programs led by International Organizations (IOs) and Non-Governmental Organizations (NGOs) to governmental programs that address children’s rights in urban slums and poor rural areas. For my case study, I selected projects that have been independently evaluated to study the mechanisms that contributed most to the achievement of their objectives. During a three-month research stay in Bangladesh, I conducted problem-centered interviews with IOs, NGOs, and Bangladesh Government Officials to gather more data on implementation processes. I also collected observational data via field visits to the project locations and by talking to participants. These field notes summarize my observations and findings after visiting and analyzing two projects.

1. Global Child Rights Agreements

The Government of Bangladesh commits itself to numerous global child rights agreements, including the 1990 United Nations Convention on the Rights of Child (CRC). On August 3^rd, 1990, The Bangladeshi Government ratified the CRC with only a single reservation. The principles of this convention, summarized as the views of the child, include non-discrimination, consideration of the best interests of the child, the right to life, survival, and development, and the idea that children’s opinions must be heard and taken seriously. The CRC highlights the need for free and compulsory education, the entitlement to the highest attainable standard of health, protection from economic exploitation and from work that interferes with children’s education and health, and time to rest and play.

On March 12^th, 2001, Bangladesh also ratified the 1999 ILO Worst Forms of Child Labour Convention. This convention calls for the immediate elimination of the worst forms of child labor defined as (a) all forms of slavery or practices similar to slavery; (b) child prostitution or pornography; (c) the use, procuring or offering of a child for illicit activities, such as drug trafficking; and (d) work which is by nature and circumstances likely to harm the health, safety or morals of children. Forms of labor that jeopardize children’s mental, physical or moral wellbeing are called hazardous child labour and their abolition is mandated as a priority for ratifying State Governments.

An additional international standard of global child rights, which Bangladesh still refuses to legally commit itself to, is the 1973 ILO Minimum Age Convention. This convention demands that ratifying governments determine a minimum age for employment. For countries with less developed economies and education systems, the minimum age for entry into work should be no less than 14 years.

2. National Legislation and Policies in Bangladesh

There are also national policies in Bangladesh that concern child labor. Several parallel national acts define various ages for legal admission to the labor market between 12 and 18 years of age. These rules and acts only partly reflect the regulations of the ILO Convention on Minimum Age, but are generally in tune with the ILO Convention on the Worst Forms of Child Labour. Apart from this rather antiquated national legislation, there are few national laws and policies that promote child rights. One policy, the Compulsory Primary Education Act (1990), attempts to achieve universal primary education in accordance with the CRC. After 1993, a compulsory primary education system was established in Bangladesh and in the following years, the Government significantly increased its budget. The Constitution of the People’s Republic of Bangladesh contains two major ratified principles of international children’s rights, namely free and compulsory education and the prohibition of forced labor.

After 1992, there were attempts to rearrange this group of rules and regulations under a single umbrella legislation. Finally, in 2006, the new Labour Code was passed, including national standards that reflect the 1973 ILO Minimum Age Convention. To respond to the ratification of the ILO Worst Forms of Child Labour Convention, several drafts of a National Child Labor Policy are now circulating among government officials, IO experts, local NGO staff, and academics. Even though it has not yet been adopted, signals are positive that a final draft will be passed within the foreseeable future.

Altogether, national legislation and policies pertaining to child protection are inconsistent, but newer regulations are becoming more effective. Nevertheless, even if these national laws constitute a necessary condition for the promotion of children’s rights, they do not sufficiently assure that these rights will reach the children at the grassroots.

3. Project Interventions Transporting Rights to the Local Level

Legally protecting and reaching out to poor and underprivileged children in urban slums and rural areas of Bangladesh is a challenge. Two different interventions that aim to transport principles of children’s rights to the local level are introduced here. First, the Bangladesh Government initiated Food for Education programs in target rural areas to promote the right to free and compulsory education as defined in the CRC. In 2002, the governmental Food-for-Schooling program turned into a Primary Education Stipend (PES) Program because of leakage in food distribution. Second, the ILO project “Prevention and Elimination of Selected Worst Forms of Child Labour in the Informal Economy in Dhaka City” promotes the immediate elimination of hazardous child labor in urban areas. To analyze the programs’ strategies, mechanisms, and actors, I undertook several problem-centered interviews with relevant governmental and nongovernmental experts, informal interviews with project participants, and on-site field observations.

3.1 Food for Education

The Government of Bangladesh initiated the Food for Education (FfE) program as an incentive to increase school enrollment and reduce dropout rates. One essential strategy was the use of a two-step targeting mechanism to help reach out to the most needy. In the first step, economically aggrieved areas with low literacy rates were selected. Within these areas, households with primary school aged children were eligible to participate if they met at least one of the following conditions:

§ The family was landless or owned less than half an acre of land;

§ The parents were day laborers;

§ The household was female-headed;

§ The parents were engaged in certain low-income occupations, such as fishing, pottery, or blacksmithing.

Beneficiary households were entitled to receive a free monthly food ration, in the form of up to 20 kilograms of wheat or 16 kilograms of rice, if their primary school aged child attended school on a regular basis (at least 85 percent of classes). The families could either consume the food ration or sell it for cash to satisfy other basic needs. Local government structures like the School Management Committee and private food retailers arranged the food distribution and project implementation.

Tapan Kumar Chakravorty, Deputy Director of the Primary Education and Stipend Program in Bangladesh’s Ministry of Primary and Mass Education, told me about the challenges that the FfE faced. The challenges he identified had to do with project management, time constraints, manpower constraints, and the rise in food price. However, he did not mention the harmful influence of heavy leakage, corruption allegations found by the International Food Policy Research Institute (IFPRI). Private food retailers did not distribute the designated amount of wheat or rice to the beneficiaries and too much food got lost on the way to the ones in need.

As a response to the problems that the program faced, the FfE program turned into a Primary Education Stipend Project in 2002. Eligible students now receive 100 BDT per month and their mothers obtain the bankcards needed to collect the money. The conditions for participation remained almost the same. Students now have to attend at least 85 percent of classes and achieve 40 percent pass marks. A 2002 IFRPI evaluation revealed that school enrollment increased by about 35 percent, particularly remarkably for girls, whose enrollment increased by 44 percent. It is also important to note that the program has helped raise awareness of children’s rights: As Mr. Chakravorty told me, “The teachers are telling the students that it is your social right; you must be educated. […] education for all is the government commitment.” Additionally, attendance rates have risen, dropout rates have decreased, and the quality of education has improved as it becomes less disturbed by fluctuation. As of 2008, 5.5 million students receive the stipend in 65,000 primary schools in rural Bangladesh.

Gorad Government Primary School in Savar Upazila was one of the first schools to introduce the FfE program in 1993. Miah Mohammed Kahlilur Rahman, the headmaster, told me that after the program was introduced, enrollment increased significantly. However, the right to education created unexpected problems; for instance, there were not enough teachers or enough space after the enrollment increase. The Parents and Teachers’ Association and the School Management Committee solved these problems by hiring voluntary, unpaid honorary teachers. Two program beneficiaries who I talked to, Sonia and Uzzale of class 5 of Gorad Government Primary School, explained that they can even use part of the money for a private tutor who helps them advance their learning achievements. They said that without these benefits it would be hard for them to regularly attend school.

May-July 2008. Savar, Bangladesh: Classroom at Gorad Government Primary School.

When I visited the classes, the effect of the program was obvious. In the first class, 74 of 92 total students were present. Of the 30 students in the class who received a stipend, 29 were in class. According to Mohammed Abdul Aziz, an Upazila Education Officer in Savar, all unions in Bangladesh are now covered with the stipend program. This is another advantage over the FfE, which only reaches the poorest areas. Still, due to financial constraints, only 40 percent of the students in program schools are eligible to receive the stipend, a challenge that remains to be addressed.

My visit to this project site also revealed opportunities and challenges of undertaking grassroots research in developing countries. Because the Education Officer and District Monitoring Officer accompanied me to the school, I was easily able to gain access; however, it was also almost impossible to discuss difficulties with participants due to the presence of my official companion. The classes at the primary school seemed to be showcased to me as an example, as they had a high number of attending students who took classes in relatively well-equipped classrooms. After visiting with students, I ate lunch with the headmaster and a few teachers. The lunch was luxurious for that part of Bangladesh, however the interpreter—a government official—blocked my critical questions about attendance rates and the possibility of students continuing to be involved in child labor.

May-July 2008. Savar, Bangladesh: school children at Gorad Government Primary School.

The World Food Program continues the FfE Program with its own component called the School Feeding Program. The short-term objectives of the program are identical to the FfE project, namely to improve school enrollment and attendance and to reduce the number of dropouts. However, according to Shahida Akther, Project Officer at the World Food Program in Bangladesh, it is unfeasible to give a cooked school meal to every student in Bangladesh, the most densely populated country in the world. It is too difficult to handle the cooking along with space problems at school facilities. The School Feeding Program responds to these challenges by providing high nutrition biscuits to children as an incentive to attend school regularly. One package of biscuits contains 67 percent of the recommended daily nutrient intake for each student. Teachers hand out the biscuits in the morning so children do not have to be hungry during class. The distribution of biscuits is conditional on regular school attendance and the teachers have to ensure that students finish their package in class and do not take it home to sell or share it with others. Additionally, health services are delivered to program participants.

Together the FfE Programs and the Governmental Primary Education Stipend Program have promoted the principles set forth in the Convention on the Rights of the Child, including the best interests of the child, the right to life, survival and development, the need for free and compulsory education, the entitlement to the highest attainable standard of health, and protection from economic exploitation and work via regular school attendance. Increased school enrollment and attendance indicates that engagement in the worst forms of child labor is prevented. Therefore, the program indirectly fosters principles in accordance with the ILO Worst Forms of Child Labour Convention. The sophisticated targeting mechanism ensures that these principles of global norms are transported to the local level.

3.2 Prevention and Elimination of Selected Worst Forms of Child Labour in the Informal Economy in Dhaka City

The project entitled “Prevention and Elimination of Selected Worst Forms of Child Labour in the Informal Economy in Dhaka City” was launched in 2001 by the ILO’s International Programme on the Elimination of Child Labour. The program aimed to address hazardous child labor in Bangladesh. Out of an estimated 1.3 billion Bangladeshi children who are engaged in hazardous child labor, 90 percent are involved in the urban or rural informal economy.

The project strategy included the following four components:

(a) Social Protection;

(b) Monitoring, Verification, and Tracking;

(c) Advocacy and Awareness;

(d) Capacity Building.

After a child withdraws from a hazardous workplace, three complimentary modules provide economically and socially viable alternatives for his or her family. A local NGO, Dhaka Ahsania Mission (DAM), helps provide project participants with Non-Formal Education (NFE). NFE is a yearlong, child-friendly reintroduction to education, generally comprising of two-hour, daily sessions held in community-owned Multi-Purpose Centers. After completion of this reintroduction program, younger children are integrated into the formal education system while older children move on to participate in Skills Development Training (SDT). Another local NGO, the Underprivileged Children’s Educational Program (UCEP), which specializes in vocational training, provides these skill development courses. Course options include motorcycle repairing, refrigeration and air conditioning, signboard and banner writing, embroidery and jori-chumki, tailoring, and dressmaking.

The Social and Economic Empowerment (SEE) component of the program targets the parents and guardians of former child laborers and seeks to provide them with an economic alternative to the children’s lost income. The Resource Integration Centre (RIC), another Bangladeshi NGO, provides mothers of working children with a micro credit of 5,000-25,000 Taka depending on what kind of business they want to start. The SEE component also provides women with business training to help them gain success in self-employment.

May-July 2008. Dhaka, Bangladesh: The hazardous workplace of children in an informal biscuit factory. Laborers kneel on the floor during their long working day; the huge oven in this tiny room creates an extremely hot environment. The factory owner revealed that he can only maintain his factory if he employs cheap laborers, predominantly child immigrants from rural areas who are, from a legal perspective, too young to take up employment.

Impact assessments showed that of the 30,000 children who enrolled in the Non-Formal Education component of the ILO/IPEC project, about 20,000 completed the course. Children who graduated from the NFE component also significantly improved their health status. A change in attitude regarding child labor became apparent as more participants became convinced that children should not start working at such a young age. Only 180 children have graduated from skills development training; this low graduation rate can be attributed to the fact that the SDT component had to be redesigned throughout the project when it did not meet the determined objectives. Nevertheless, more than 90 percent of the SDT graduates found a decent workplace. Lastly, about 9,500 guardians and parents of former child laborers received micro-credit through the SEE component of the project. Those participating in three loan cycles experienced a significant increase in economic wellbeing.

Ronald E. Berghuys, ILO/IPEC Chief Technical Advisor in Bangladesh, attributed the success of the program to its comprehensive and participatory approach, and especially the fact that the community took over program ownership. During the targeting process, very poor children could be identified at hazardous workplaces and were convinced to take part in the project. Before this project intervention, children had been unaware of their rights: “They are surviving in an urban jungle,” said Mr. Berghuys, “The notion that they have certain rights is very often simply not there. And that’s also sustained, of course, by, let’s say, by overall society.”

To speak with some of the project’s participants, I visited Hazaribagh and Lalbagh, target areas in of the ILO/IPEC project. I felt like a gatecrasher when I entered this independent entity at the margin of the mega city of Dhaka. It appeared like a world of its own, with its own structures, laws, citizens, and authorities, and I left with a sense of not having learned enough. Finding a particular spot in Hazaribagh seemed impossible if you were unfamiliar with the area, especially as a “bedeshi,” a white foreigner—while in Hazaribagh, I attracted the attention of the locals who did not hesitate to show curiosity and question my country of origin. The slum was overcrowded with informal businesses and houses, as well as littered with leather shreds from the tanneries, garbage rifled through by crows, goats, and countless flies. Cooking smells mixed with the smoke of informal shops and the stink of human excrement on unfortified tiny paths, which during monsoon time turned into smelly muddy creeks; the water on these creeks reflected the colors of the nearby factory’s chemicals.

One of the most impressive encounters I made in Hazaribagh was with a group of ILO/IPEC beneficiaries who break with ingrained gender roles and family traditions to struggle for a brighter future of their formerly working children. The women’s group I met was comprised of 22 enthusiastic female business owners cramped into a single room in one of their homes. The ILO field workers who guided me and my companion, a Dutch researcher, to Hazaribagh translated our informal interviews. Once a week, the women get together to pay back dues and discuss problems related to their new self-employment in the urban slums of Dhaka. They seemed shy at first, quietly watching us while sitting on the floor and offering us the only comfortable seats on the bed. However, the longer we remained their guests, the more thrilled they became about sharing their experiences in the ILO micro-credit program. Their children had formerly been working in the leather industry, but now the women acted as breadwinners, buying and lending out rickshaws, garments, or dishes on the market, or doing block and batik printing.

May-July 2008. Dhaka, Bangladesh: women’s group receiving micro-credit.

When I asked if their children still worked, the women became enraged and loudly exclaimed replies at the same time. They felt it was a mistake that their children worked earlier, they told me. Now the children were in school and not employed because school education is more profitable in the long run. Also, with the help of their businesses and micro-credit possibilities, the women could afford the school costs. After school, the children engaged in homework, reading, and playing; some of them even saw a private tutor. However, the women’s experience in the SEE component of the program hadn’t run altogether smoothly. They frankly referred to the problems they faced, like the fact that some of their cycle rickshaws had been stolen. But in cases like these, they stuck together and profited from a common pot of savings.

My experiences studying the “Prevention and Elimination of Selected Worst Forms of Child Labour in the Informal Economy in Dhaka City” program led me to believe that the principles anchored in the ILO Convention and the Worst Forms of Child Labour reached project participants at the grassroots level. The program also addresses the rights set forth in the CRC regarding education, health, and development. Principles like free and compulsory education and entitlement to the highest attainable standard of health were also reflected in the project objectives and promoted with the help of this ILO/IPEC project. Despite the fact that the ILO Minimum Age Convention has not been ratified in Bangladesh, its basic principles have still been promoted through enrolling working children in non-formal education and providing them with skill training when they reach the legal age of employment. Through a targeting strategy aimed at catering to needs of child laborers engaged in hazardous occupations, local NGOs have reached the working children in the Dhaka slum of Hazaribagh.

4. Conclusion

As seen in these case studies, the process of implementing child rights norms can be successfully traced from the global to the local level. After the ratification and adoption of international children’s rights, certain interventions were necessary for these rights to reach the grassroots level. These interventions were largely successful; however, problems still existed, including management problems, corruption, and ignorance about the root causes of the child rights situation, such as education deficits and socio-cultural perceptions. In order to achieve a sustainable impact after these projects have terminated, it is essential to create an environment for change, a community awareness of children’s rights, and a demand for the provision of all rights-related services that the government has committed to provide. If this is accomplished, protected and empowered children may break the cycle of poverty and contribute to a process of sustainable development. Reaching out to children in developing countries who are deprived of their basic rights remains a challenge, but the programs mentioned here have been largely successful in achieving their goals by using sophisticated targeting procedures, increased awareness, capacity building, and community ownership of project initiatives.

Works Cited

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Matthew Cummings

mj24cumm@siena.edu

Matthew Cummings is a senior at Siena College where he is studying biology and history.  He spent the fall of 2007 at Makerere University in Uganda and worked with the Epidemiology and Surveillance Division at the Uganda Ministry of Health throughout the summer of 2008.  During this time he participated in field investigations and control activities related to outbreaks of cholera, hepatitis E, typhoid, and Marburg hemorrhagic fever. 

Acknowledgements:  The author would like to thank Mr. Luswa Lukwago, Dr. Joseph Wamala, and the entire staff of the Epidemiology and Surveillance Division at the Uganda Ministry of Health for their encouragement and support during the activities described in this article.

Scholarly Abstract

While outbreaks of communicable diseases have long presented an ongoing challenge in the developing world, within recent years the frequency of such outbreaks has risen sharply.  Accordingly, it is clear that strong epidemiological surveillance and response is needed to improve the health of disadvantaged populations in developing nations such as Uganda.  Such populations face the greatest threat from communicable diseases and are more likely to fall victim to illness due to their poverty.  In Uganda, the implementation of Village Health Teams (VHTs) has laid the groundwork for establishing community-based surveillance and response systems that can provide early notification of outbreaks and prevent the unnecessary suffering that accompanies unrecognized epidemics.  Local response programs can also help to identify opportunities for the implementation of sustainable preventive measures and health education activities that will be able to improve the overall welfare of those living in settings of poverty.  

Author’s Note

My experiences in Uganda have reinforced my belief that access to health care is a fundamental human right.  After learning about the concept of Village Health Teams and their ability to improve healthcare in impoverished and isolated communities, I immediately knew that I wanted to convey their importance to others.  Empowering Village Health Teams provides an opportunity to work with the poor to reclaim their right to health.  While in Uganda, the high levels of poverty and disease that I witnessed confirmed my desire to pursue a career in medicine and to volunteer my time to work with the underserved.

Keywords: epidemiology, communicable disease control, medicine, equity

Communicable Disease Surveillance and Response in Uganda: Community-Based Disease Surveillance, Prevention, and Response as an Essential Tool for Improving Health in the Developing World

In reflecting upon my first trip to Uganda in the fall of 2007 and my subsequent stay throughout the summer of 2008, I have become acutely aware of the need for communicable disease surveillance, prevention, and response in regions that are at-risk for outbreaks of epidemic-prone illnesses.  Epidemiological surveillance and response is an integral tool for improving the health of disadvantaged populations, as they are more likely to fall victim to communicable illnesses due to their poverty.  Providing routine surveillance in these locations can help prevent unrecognized outbreaks.  Additionally, the increase in communicable disease outbreaks demands amplified surveillance of these pathogens in order to prevent large-scale epidemics.  Such epidemics undoubtedly have the potential to threaten the livelihoods of those living in at-risk areas and may hamper the development of the communities in which they reside.  

While studying at Kampala’s Makerere University in the fall of 2007, my academic program allowed for a practicum period during which I researched the medical, social, and economic factors preventing more effective anti-retroviral therapy for HIV/AIDS in a rural area of Uganda.  During my time at Makerere’s School of Public Health I met Mr. Luswa Lukwago, an epidemiologist from the Uganda Ministry of Health (MoH).  Mr. Luswa grew up in a rural village similar to many of those he visits as part of his fieldwork today.  He has a master’s degree in public health with a specialization in communicable disease outbreak response, and is currently earning his doctorate in public health.  As a member of the Makerere/MoH Integrated Disease Surveillance and Response Program, Mr. Luswa fulfills his duties as a field epidemiologist and helps train the next generation of Ugandan public health workers.  Throughout the semester I regularly stopped by Mr. Luswa’s office to discuss the epidemic control efforts that he was helping to coordinate throughout the country.  While my work at this time focused on HIV/AIDS treatment, my meetings with Mr. Luswa at the MoH provided me with a window into the epidemiology and surveillance activities of Uganda.  My interest in these fields had been sparked and I knew that if I was able to return to Uganda, working with Mr. Luswa and his fellow epidemiologists would be at the top of my agenda.

Cholera

When I returned to Uganda in May 2008, I worked with Mr. Luswa at the Epidemiology and Surveillance Division at the MoH.  Mr. Luswa and his colleague Dr. Joseph Wamala were coordinators of communicable disease outbreak response throughout the country.  At the time of my arrival, one of their primary concerns was the increasing intensity of an outbreak of cholera in eastern Uganda.

Cholera is a disease caused by infection with the bacterium Vibrio cholerae.  Among humans, the infection frequently presents mildly or asymptomatically and only develops as severe illness in a small percentage of the population.  However, in this symptomatic group, infection results in massive diarrheal discharge of a “rice-water” stool as well as intense vomiting.  The V. cholerae bacteria exit the human body in this stool and can typically be found in bodies of freshwater.  In many parts of the developing world, contaminated water sources provide the drinking water supplies for countless communities and therefore provide the link in the bacteria’s fecal-oral route of transmission.  Following consumption of infected water, untreated cholera can cause death within hours of its onset.  This rapid death is caused by massive fluid loss and the ensuing dehydration from the diarrhea and vomiting described above.  

Typically, well-handled epidemics of cholera result in a case fatality rate (the proportion of recorded deaths among those presenting with the disease) of about two percent.  However, the outbreak in eastern Uganda had a reported case fatality rate of about seven percent.  In order to address the high number of deaths, the MoH sent Dr. Wamala to the east to evaluate the response capacity of the cholera-affected districts.  He planned to assess the control effort and offer education and guidance to the local area health teams if needed.  I was privileged to travel with him.

It must be noted that in many cholera outbreaks, inadequate treatment is frequently found to be the basis behind an unusually high amount of fatalities.  However, before our departure, members of the humanitarian organization Médecins Sans Frontières/Doctors Without Borders (MSF) informed us that poor case management and treatment did not cause the high fatality rates in the eastern Uganda outbreak.  MSF often handles much of the clinic duties of an epidemic response and they confirmed that their staff had been treating cases appropriately and were successfully training local health workers.  Eventually, health officials and community leaders in the east revealed that many of the early cholera deaths occurred among people who had not been able to make it to a treatment center in time.  Often the illness was not recognized as life threatening by the affected individuals, their families, or their peers.  Eventually, they became too ill to travel to treatment centers to seek care. 

To fully determine the specific factors that had discouraged local residents from seeking care, further investigation was needed at the community level.  Due to the fecal-oral method of transmission of cholera, Dr. Wamala and our group from MoH conducted an assessment of sanitation and hygiene practices in the region.  Once the team identified these factors, a corrective plan could be put in place to address them.

Village Health Teams and Cholera

In order to fully understand the importance of local engagement in an outbreak response, the concept and role of the Village Health Team (VHT) must be explained.  VHTs are the “eyes and ears” of the control effort in any potential or confirmed outbreak.  They are members of the local population who are elected by their peers and trained to recognize suspected cases of epidemic-prone diseases and to provide basic health education to their communities.  While local healers have been mainstays in these communities for generations, the MoH only recently began an official program to organize and train VHTs in Uganda, beginning in 2000.  With training assistance provided by organizations such as the World Health Organization (WHO) and UNICEF, VHTs were established in 40 districts (50% of the nation) by 2008.

VHTs, or “village doctors,” as they are sometimes referred to locally, are trained to identify individuals who present the standard case definition of a serious illness and require the attention of health facility staff.  Additionally, they are trained to disseminate “Information, Education, and Communication (IEC)” materials, which alert the community to epidemic threats and promote healthy living.  They are also trained in contact tracing, which entails following up on contacts of infected individuals during an outbreak of a communicable disease to help halt transmission chains.  Lastly, the local knowledge and trust that VHTs possess is invaluable when outside investigators are navigating unknown terrain or attempting to gain insight on area-specific customs and practices that may be affecting disease patterns.  As they are local residents themselves, VHTs understand the needs of their communities and can relay this information to others. 

“Information, Education, Communication” (IEC) materials in an eastern Uganda health center during the response to the cholera outbreak.

In response to an outbreak of a disease like cholera, VHTs can dispense initial oral rehydration solution to affected individuals before their arrival at a treatment center.  VHTs also provide instruction on maintaining healthy hygiene and sanitation within their communities, such as the need for consistent hand washing and the installation and use of proper latrines. 

Training of VHTs on proper hand washing techniques.

During our meetings with the VHTs in the eastern, cholera-afflicted district of Pallisa, Dr. Wamala assessed the VHT members’ general knowledge of epidemic-prone diseases such as meningitis, measles, and viral hemorrhagic fevers like Ebola and Marburg.  He placed a special emphasis on the hygienic standards necessary to prevent and control cholera.  Several of the VHT members were impressively conversant concerning the symptoms of cholera and the appropriate steps to take after recognizing a suspected case.  There were, however, inconsistencies in the knowledge base of other members concerning these issues.  Some members of the community were unaware of the symptoms of the disease and others did not know how it can spread.  During some outbreaks, elements of sorcery may be blamed for the transmission of the disease and such beliefs can impede necessary interventions.  Therefore, education about the fecal-oral route is an important aspect of social mobilization during a cholera outbreak as it helps prevent the spreading of inaccurate and dangerous misinformation. 

Another issue that Dr. Wamala and I encountered in Pallisa was the reluctance of some members of the community to purify their water using chlorine tablets and construct new pit latrines in areas sufficiently isolated from communal water sources.  Through conversations with the VHTs, we found out that the bitter taste that chlorine tablets produced when combined with drinking water led to resistance to the use of these tablets among community members.  Dr. Wamala explained to the VHTs that while we understood their concerns with the unpleasant taste, the crisis at hand required a compromise.  Many of the VHTs then agreed to increase their water purification efforts. 

Later, Dr. Wamala and I learned that new latrines were not being built due to a shortage of the concrete slabs needed for their surfaces.  There was also a lack of understanding in the community concerning the immediate need to build new latrines.  In addition to realizing the need to increase the availability of the slabs, Dr. Wamala urged the VHTs, many of whom had improper latrines themselves, to construct new, isolated ones and to encourage their neighbors to do the same.  The importance of sanitation and hygiene during a cholera outbreak cannot be overstated, and failing to prevent infected latrine waste from contaminating water sources and neglecting to purify drinking water are two main vehicles by which cholera spreads.  Based on the information gained in our meetings, Dr. Wamala and I realized that additional sensitization training of these community health leaders regarding sanitation and hygiene was imperative in order to completely end the epidemic. 

After our departure, the Pallisa District implemented an unusual policy in an attempt to boost latrine construction.  It mandated that residents of cholera-stricken areas who had latrines located too close to water sources would be penalized with the seizure of livestock until they constructed a proper latrine.  While many local residents were clearly upset upon hearing this threat, the policy did succeed in encouraging proper latrine construction, and the number of latrines in the cholera-affected areas increased.  This increase undoubtedly contributed to the decrease in new cholera infections.

In addition to knowledge-enhancing trainings, there were also tangible items necessary to stop the epidemic, such as water purification tablets, soap, and supplies for constructing pit latrines.  The sub-counties of Pallisa District where the outbreaks were centered were very rural and populated primarily by poor subsistence farmers residing in mud- or brick-walled and thatch- or tin-roofed huts.  These huts were organized into small homesteads and villages.  Latrine shortages were already rampant and clean water sources were far from ubiquitous.  During our time in Pallisa, communities needed hand soap, water purification chlorine tablets, and concrete slabs for pit latrine surfaces in order for local interventions to be effective.  These logistical and supply problems are not unusual in other resource-limited districts of Uganda. The work of VHTs is challenging in itself and nearly impossible to complete if they do not possess the necessary supplies.

Following the assessment, Dr. Wamala met with the National Task Force on Cholera and Hepatitis E and recommended that VHT training be enhanced.  He also recommended increasing the availability of the supplies mentioned above in an effort to improve community levels of sanitation and hygiene.  By increasing the capability of VHTs to recognize suspected cases of cholera, in addition to affording them the materials necessary to prevent the spread of the disease, the chain of transmission could be stopped. 

Ultimately, the eastern cholera epidemic came to an end in early fall 2008.  After my departure, smaller epidemics arose in sections of Kampala and more recently, in the central district of Kayunga.  As discussed previously, many causes contribute to an outbreak of cholera.  Therefore, it is difficult to identify one factor in particular that leads to its resolution.  The crux of the response is often found at the grassroots level.  Education and sensitization efforts, proper case management and surveillance, the availability of adequate supplies, and maintaining local involvement all contributed to the halting of the epidemic.  VHTs understand and respect the local culture.  As a result, they are an integral aspect of all of these interventions.

Pallisa District, eastern Uganda. (Standing in foreground: Dr. Joseph Wamala.)

Conclusion: VHTs and Community-Based Control of Communicable Diseases

While communicable disease outbreaks have long presented an ongoing challenge in the developing world, within recent years the frequency of such outbreaks has risen sharply.  Among others, outbreaks of Ebola and Marburg fevers, cholera, meningococcal meningitis, bubonic plague, hepatitis E, and measles occurred during my collective time in Uganda. 

In addition to the three pandemics of HIV/AIDS, tuberculosis, and malaria (which demand their own reviews and will not be covered here), other communicable diseases continue to take a devastating toll on those living in settings of poverty.  Despite the unrelenting nature of such outbreaks, the good news is that many of these diseases are preventable.  In situations where prevention fails, timely recognition and response can substantially decrease the mortality rates of epidemic-prone diseases.  Early recognition of the signs and symptoms of the illnesses may help to prevent the negative social and economic consequences that accompany unrecognized outbreaks.  As illustrated previously, VHTs and a community-based approach towards implementation of these practices is essential.

After Dr. Wamala and I visited the cholera-affected communities in eastern Uganda, it was clear that the creation and maintenance of adequate village-level surveillance systems was a key factor in ensuring that afflicted individuals were being recognized and initially treated by VHTs.  Early detection of the illness by the villagers themselves enabled them to recommend that their neighbors seek care earlier.  The epicenters of the outbreak were in remote corners of Pallisa District and were isolated from advanced health centers, and early identification and care were essential in providing symptomatic individuals enough time to reach a treatment unit before they became severely dehydrated.  The early reporting of cases by VHTs to other health workers, along with the transportation of affected individuals to treatment centers, will most likely decrease the fatality rate of epidemics of cholera and similar diseases in remote areas.  

To effectively contain outbreaks when prevention falls short, a support structure from the ground-up is needed to ensure that reports of “strange,” or suspected epidemic-prone diseases, are given timely attention and adequate resource allocation.  Reports of what people refer to as “strange diseases” are not uncommon in Uganda.  In many instances, reported cases of the diseases are promptly contained; sometimes they are actually determined to be unfounded.  There is, however, the possibility for an explosive and difficult-to-contain outbreak as seen in eastern Uganda.  VHTs are usually the first to encounter reports of “strange” illnesses and have the power to notify those within the extended health care system or those at even higher levels of care.  Well-trained and experienced VHTs possess the knowledge of warning signs and symptoms of various diseases.  This should certainly be the case for diseases with hallmark indicators such as “rice-water” stool in cholera or a stiff neck in meningitis.  Rapidly identifying these diseases can lead to enhanced containment measures and interventions.

As mentioned earlier, VHTs can also provide invaluable assistance during an outbreak by teaching outside investigators how to address local traditions and customs that may play a role in controlling the epidemic.  An awareness and respect of local cultures works to gain the trust of the population.  This trust is indispensable during contact tracing activities, one of the most important aspects of epidemic control.

It is important that VHTs are in positions to lead by example.  If they cannot, it may prove impossible to relay health information to entire populations.  As emphasized earlier, village teams can provide instruction on proper hand washing, appropriate sanitation, and hygiene promotion activities.  Additional education on topics ranging from HIV/AIDS prevention to safe child-delivery and nutrition can be carried out by VHTs in their communities as well.  The village doctors can provide local leadership and set ideal examples for their peers.  VHT programs possess the unique ability to empower the impoverished and provide a bridge to health for the sick. 

With community and VHT members (standing second from left: Mr. Luswa Lukwago).

Works Cited

Komakech, Innocent.  “Village Health Team Strategy is a Most Innovative Community       Practice Award Winner: the Experience of a Village Volunteer Programme in              Yumbe District, Uganda.”  Health Policy and Development 5.1 (2007): 21-27.

Innocent Komakech, “Village Health Team Strategy is a Most Innovative Community Practice Award Winner: the Experience of a Village Volunteer Programme in Yumbe District, Uganda,” Health Policy and Development 5.1 (2007): 21-27.

Kartikeya Singh

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Abstract
Approximately 500 million people in India’s countryside are still without access to electricity. The government has launched an ambitious project to electrify the entire nation by 2012. Unfortunately, the term “village electrification” defines electricity distribution for only 10% of households. An equally ambitious plan by the Ministry of New and Renewable Energy aims to to electrify about 25,000 of the remotest villages in India. In these villages, it is inefficient to extend an energy grid rather than develop decentralized, renewable energy systems. The economic development of a large portion of India’s population depends on the success of decentralized energy distribution. This development will help provide the means to eradicate poverty. Ensuring the success of these systems requires a closer look at the rural energy ladder. One must go beyond just lighting in order to establish a paradigm for integrated sustainable energy independence for India’s rural villages. Whether India decides to power its villages through grid-fed coal power or through decentralized renewable energy systems, this decision has major implications for global climate change. This study assesses the benefits and drawbacks of one such distributive power system: solar home lighting.

One and half years ago, Grameen Surya Bijlee (a Mumbai based non-profit), distributed LED (Light Emitting Diode)-based solar home lighting systems to 52 homes in the remote village of Dabkan, in the tribal area of the Alwar District of northeastern Rajasthan. The home lighting systems in Dabkan consist of one 10-watt solar photovoltaic panel, one 12-volt battery, and two 21 or 33-light LED bulbs which provide four to six hours of light. “There was nothing here ten years ago except jungle, and we were only connected to the outside world when the road was built” explained Babu Lal, the only shop owner in the village. Because of the road, one of the men running Grameen Surya Bijlee stumbled across the remote village with a truck full of supplies that they were unable to install in another village. As independent analysts, Dave Madan and I traveled to this village to assess the impacts of the solar home lighting systems on its families, as well as the problems, the benefits, and the barriers to successful continuation of such a lighting scheme in this part of Rajasthan or any other part of India. This assessment was for the benefit of not only Surya Bijlee but also the Renewable Energy Corporation of Rajasthan, which has to date installed approximately 90,000 solar home lighting systems throughout the state.

Common 10-watt solar photovoltaic panel, Alwar District, Rajasthan

Rural India’s Dilemma
Approximately 500 million people in India’s rural areas have yet to see the light of “India Rising,” as the media has literally described the recent economic growth. 700 million people in rural India are still dependent on biomass fuel for their energy needs and as many has 500 million people still have no access to electricity. The government’s ambitious plan to electrify the entire nation by 2012 is in large part based on providing these homes (particularly some 25,000 of the remotest villages) with decentralized renewable energy systems. Decentralized renewable energy systems consist of local energy generation and dissemination systems unlike a large national or regional grid. It is important to add that when the government says “rural electrification,” it means providing electricity to a mere 10% of the households in a village. Thus, decentralized renewable energy systems (as opposed to just the extension of the national grid) offer the best hope for a more complete electrification of India’s villages. There are many types of such systems depending on local availability of resources (micro-hydel, solar, biogas, bio-mass gasification, etc.). However, for this part of the country, solar energy is the best option because of year round availability of high solar radiation. Also, LED – the next revolution in energy-efficient lighting – is helping people in the dark leapfrog into a new era of home lighting. This new LED revolution has helped the poor by reducing their dependency on dirty kerosene, which consumed much of their meager income and was injurious to their health.

LED bulbs held by a villager in Alwar District, Rajasthan

System Drawbacks
Unfortunately, after five to six months of use, approximately 60% of the bulbs that were distributed have sustained some level of damage. Most importantly, the bulb holders have broken and individual LEDs have fused within the bulb (some reporting 10-15 fused LEDs in a bulb). This could perhaps be due to the poor quality of manufacturing of the bulbs. The various parts of the system were sourced from China and distributed as Surya Bijlee’s products. The occasional solar panel is also damaged due to incidents involving monkeys, peacocks, and even rats eating the wires. These are all important factors to consider when designing future home lighting systems for rural areas. All of the recipients were adequately trained in the maintenance of the system. The villagers essentially only needed to keep one foot by one foot thin-film solar panel clear of dust, because the dust can affect the efficiency of the system, particularly in a desert environment. One of the other questions is of brightness of the system. “When we provide light, our [Compact Fluorescent] bulbs give off 600 lumens whereas [Surya Bijlee] provides only 100 lumens of light,” exclaimed Sudir Mohan, head of Rural Electrification at India’s Ministry of New & Renewable Energy Sources, the only government agency dedicated entirely to such a cause anywhere in the world¹. At first sight, it appears that this really isn’t enough light. When asked about the amount light the bulbs emitted, approximately 70% of the respondents claimed it was adequate lighting but most agreed it could be brighter. At night, the effect was clear. In a sea of darkness, the small LED bulbs made a large difference. We could see the light created by the bulbs from far off and the light seemed adequate to extend work hours, keep the bugs out of the food while eating, and even keep the scorpions and snakes at bay. It perhaps was not the best lighting for reading, but the LED bulbs still made a difference by alleviating some of the major concerns of the villagers.

Benefits
“We are very happy with the system and we would like more installations,” said one of the villagers. Indeed, the lighting systems benefit the villagers immensely in terms of general lighting needs. The majority of the respondents of the survey said they used the LED-based lighting system to extend their work hours at night or early in the morning. The system was used specifically for their children’s studying needs as well as necessary kitchen lighting for cooking. The occasional person even used the system to charge mobile phones (there are only two in the entire village) and flashlights. The villagers dream of a day when they would be able to power fans, televisions, and even water pumps.

There are approximately 52 homes in this village with joint families having seven to eight children in each home. Formal surveys were conducted in 18 households, or 35% of all households in Dabkan, with the assistance of the village schoolteacher, Deendayal Sharma. The large majority of respondents were decision-makers within their households, and 89% fell within the labor-contributing age range of 18 to 49. 28% of respondents were women. In addition, an informal survey was conducted of several homes during the night to assess the effectiveness of the home lighting systems. One hundred percent of the respondents claimed that they had seen their children’s study habits improve after the installation of the solar home lighting system. “When I first started teaching here five years ago, most of the children couldn’t even write their names properly, and they would fail tests even when only 50-60 percent marks were required for passing,” stated the village school teacher. “It took me one and half years to just get them to memorize the prayer we do in the morning before starting school.” Thanks to the extended hours of study provided by the lighting system, there has been a 70% improvement in retention of knowledge and on average students are studying one to three hours longer than they did before. “Our kids can study until late even after we have all gone to bed,” said Choti Devi. This is particularly important in rural areas where children often have chores until sundown, which means that they are free to study only when it is dark.

“Would you prefer electricity from the grid or from such solar installations?” I asked every interviewee. “This LED-based system, of course, because there are no bills!” bluntly stated Pal Brindiyal. The dependability of the grid was also often questioned, and rightly so in a nation which struggles to provide reliable electricity for even its urban centers. Then there is also an issue of safety: “If I get in a fight with my wife, she may go outside and put her hands on the live wires,” joked Lalu Ram, who received the lighting system just in time for the birth of his first child. The truth is that in rural areas many of the wires are uncoated so they do present a threat to people, particularly curious children. But the national grid has no prospect of ever reaching this village, because it falls within the National Forest lands. By Indian law, infrastructural development is kept at a minimum within designated National Forest Land areas. This is in large part to minimize deforestation and human-wildlife conflict which would happen with human habitations being situated close by. Because this particular village is near a famous Project Tiger reserve, Siriska (now devoid of tigers), it falls within the forest land area which provides a buffer to this wildlife sanctuary. In an effort to continue to move people away from forest areas and make it easier for the government to provide them services, people living in designated forest areas have no choice but to move out (if they want services) and advance the process of urbanization in India.

The LED bulbs reduced the village’s dependency on kerosene. According to the villagers, the light emitted by the LED bulbs was brighter than that from their kerosene lanterns. Of the people we interviewed (approximately 40% of the households with the installations), there was a 50% or greater reduction in consumption of kerosene on average. A few households, including Madav Ram’s, saw their consumption of kerosene drop from 11 liters a month to absolutely none. This has major implications for climate change as well. According to Surya Bijlee, of the 87 million homes still burning kerosene in rural areas in India and consuming 100-150 liters per annum at the expense of 2.6 kg of CO2 emitted per liter, there is immense potential to reduce the total 22 million tons of pollution being generated currently. Though this may seem meager compared to CO2 emissions coming out of developed countries, it is vital in helping rural India leapfrog past a carbon based economy.

Also, all of the interviewed villagers claimed that the home solar lighting system saved them money, because they no longer needed to purchase kerosene. This is important for households in this village where incomes are typically 10-12,000 rupees a year before expenses, and the cost of kerosene can be as high as Rs. 1800 anually, proving to be a significant dent (up to 20 percent) in the household budget. Since almost all the homes are dependent on some level of animal husbandry, Madav Singh’s response was particularly interesting.  “The light provided by the system has helped me save money because it has made the calving process easier for my animals which earlier suffered greater mortality rates during delivery.”

At the end of the visit, the lingering question of financial feasibility remained. A single home lighting system consisting of one solar plate and two bulbs costs Rs. 3,250 (approximately $80) and these poor villagers had received them for free. With no nearby outlet for repair and purchase of LED bulbs, an unsustainable island of decentralized energy production had essentially been created. There were no clear pathways for progress. Surya Bijlee hoped that the pilot project would spur the villagers to want to purchase the next system out of their own pocket money (which many do not have) or take a bank loan to finance the purchase. Seeing the benefits, approximately 80% of respondents said that they were willing to take a bank loan to finance the purchase of more home lighting systems. But who would provide these villagers with loans? It is known that interest rates for loans to villagers are very high and even the villagers themselves joked that they would take the loan “but paying it all back was an afterthought.”

The Future
Perhaps a micro-finance scheme is required for the dissemination of such technology throughout rural India. The recent formalization of a policy by the Indian government on micro-finance might help expedite such schemes. Already certain private banks are beginning to take an interest in funding small scale projects. “You see, people don’t want to pay for things,” stated Mr. Mathur, a Project Officer of Alwar District for Renewable Energy Corporation of Rajasthan. “In the past, we provided free solar home lighting systems and people refused to pay the monthly Rs. 100-200 for the new battery their system would require within two years.” Currently, a 35 kilovolt solar home lighting system, provided by Rajasthan Electronics and Instruments Ltd. which powers three CFL bulbs and has a bigger solar panel, costs approximately Rs. 10,000 base price and Rs. 6,500 after the government subsidy. One of the villagers in Dabkan had such a system and it was significantly brighter and more durable than the supposedly long-lasting LED bulbs.

12-Volt battery pack on a rooftop, Debkan Village in Alwar District, Rajasthan

When asked about consumption of wood before and after the solar home lighting system, all respondents reported no change. According to the Ministry of New and Renewable Energy, in a nation where 84% of the rural household’s energy is needed for cooking, this may be an interesting point to consider. Some villagers in Dabkan are also dependent on diesel powered pumps to bring water to their fields. “It would be nice if we could use the light from the sun to power other things,” stated the shopkeeper shopkeeper Babu Lal.  “For instance, the village mill.”

Clearly in terms of the overall energy ladder of the rural home, home lighting is filling only part of the gap. The important question is whether this offers only a “half-leap” in terms of providing for the energy needs of those in India’s countryside. “Solar is the only viable option that works across the country,” according to Mohan. “But solar is not true electrification as it can only provide lighting.” I noticed a lot of animal dung readily available in the village because nearly everyone is dependent on animal husbandry for part of their income. Perhaps it is time to consider the utility of biogas as a possible energy source for the villagers. Solar cannot be the only answer. Alternatively, integrated renewable energy systems (development that employs various renewable energy technologies in combination to provide for the various energy needs of a community) might not only pave the way for sustainable development, but might also represent an important leap into sustainable energy independence for remote areas in India, and beyond. In the case of Dabkan village, biogas, which could be harnessed through effective use of already available household biogas digester technology in India, could go a long way in making their lives more sustainable.

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Mike Halperin

Abstract
Starting in early 2003, Michael Halperin worked for two years as a Peace Corps volunteer in the indigenous Kuna island community of Ustupu, just off the Northeastern coast of Panama. His work focused on the issue of potable water and diarrheal disease. These field notes focus on the implementation of sustainable technologies and practices for clean water. Emphasized is the importance of local knowledge, partnerships, and indigenous leadership. This story chronicles a two-year process of considering, rejecting, and finally developing the most workable solution for safe water: solar water purification. Unlike boiling and chlorination, this method was acceptable to the Kuna because it does not conflict with cultural practices on the island. It is likely that this method of water purification can be sustained over time.

Starting in early 2003, I worked for two years as a Peace Corps volunteer in the indigenous Kuna island community of Ustupu, just off the Northeastern coast of Panama. My work focused on the issue of potable water and diarrheal disease. My training prior to moving to Ustupu consisted of three months of linguistic, cultural, and technical classes.

My Peace Corps training group sitting atop a newly constructed composting latrine in the town of Villa Carmen, Panama

This training, however, was not site-specific, so there was much to be learned once I moved to the village. In February of 2003, I arrived in Ustupu from the mainland after a 45-minute flight by twin-propeller plane and a brief canoe trek. For the next two years, I called Ustupu home. Almost 5,000 people live without paved roads or electricity on the island that rises just a few feet above sea level.

Main Street: Ustupu, Kuna Yala

Ustupu is one of 49 inhabited island and coastal communities in the 350-island archipelago of Panama called Kuna Yala. The Kuna gained their autonomy from Panama after a 1925 revolution. In the last century, the island – the size of three football fields – saw its population grow from one-hundred to nearly five-thousand. A maze of thatched-roof homes are narrowly separated by zigzagging pathways, and towering three stories above this labyrinth is a large blue concrete water tank, the most conspicuous feature of Ustupu’s aqueduct system.

I worked with Melvin, or more accurately, I worked for Melvin. As a salaried employee of the community, Melvin was in charge of maintaining the aqueduct system that feeds this towering blue water tank on the island from a mountain stream a few miles away. To get acquainted with the system, I nervously scaled the three-story ladder up the blue walls to the top of the tank. Melvin led the way. He explained how the entire system worked by gravity. Pointing up towards the hills on the mainland, he told me how the water enters the piping way up the hill in a stream, and then flows in the pipe down the slope of the hillside to where the water pours into a sand filtration tank. The water seeps from top to bottom in the tank, filters through the sand, and exits the tank in piping. This water then makes its way down through plantain and coconut groves to the coast, across the bay, onto the island, and up into the towering blue holding tank where Melvin and I were perched. From the holding tank, gravity again propels the water down to community spigots, distributing it in a web of half-inch plastic piping that covers the entire island. Melvin’s description of the system sounded much like the aqueduct systems I had seen as a Peace Corps trainee, so I wondered why the community was having problems with diarrheal disease.

The next step was a visit to the headwaters. Melvin and I paddled his dugout canoe across the bay to see the water source and the sand filtration system. We climbed uphill for about an hour to the water source. A white plastic pipe was encased in a concrete dam with the open end pointing upriver. Mesh wiring covered the intake and prevented large debris from entering the pipe and clogging the system.

The water source for Ustupu’s aqueduct system

Melvin and I then followed the piping downhill from the headwaters to the sand filtration tank, where Melvin told me we would find the source of the problem. A well-designed sand filtration tank should be filled with an even layer of sand.

Figure 1. Ideal Sand Filtration Tank

Figure 2. Ustupu’s Sand Filtration Tank

As we peered over the walls of the tank, however, I immediately understood Melvin’s worry. The force of the incoming water had burrowed a tunnel through the sand, essentially eliminating all filtration.

Melvin was fully aware of the problem and explained that if he collapsed the tunnel created by the rushing water, it would take too long for the water to seep down through all the sand. The increased resistance of the sand filtration would create a bottleneck and the water would spill over the walls of the sand filtration tank and be lost. Melvin’s explanation for the engineering failure seemed reasonable.

I felt that it took courage for Melvin to conclude that the city engineers from the capital who designed the system may have been at fault. The aqueduct dated back to the 1970s, and Melvin reasoned that it was probably built during the dry season, when the flow of the river was at its lowest. Once the rains came, the system, specifically the sand filtration tank next to where we were standing, was not large enough to handle the flow of water. During these early days on Ustupu, I offered Melvin moral support, but did not contribute much technologically. Over months and years I later learned from Melvin that I was indeed serving a function. Having me as a coworker, un licenciado (a college graduate), made it easier for Melvin to critique the system and voice his concerns with community leaders, who might otherwise have given the benefit of the doubt to the city engineers. On this first of many trips to view the inadequate sand filtration tank, Melvin reasoned aloud to me that unfiltered water was better than none at all. So the system was left in place, delivering what was surely contaminated water to Ustupu.

Melvin and I agreed that a larger sand filtration tank was needed, and worked with community religious and political leaders, and the Sailah (chief), to create a plan. The initial goal was to build a bigger sand filtration tank, one that would not overflow given the flow rate and quantity of water entering the system. We then approached engineers from both the Peace Corps and the Panamanian Health Ministry, and found that the cost was estimated to be nearly $300,000. We needed a more realistic solution.

An official from the Panamanian Ministry of Health proposed a solution: chlorinating the water once it reached the blue holding tank on the island. If added at a ratio of one drop for every liter (four drops for every gallon), chlorination would be a very effective purification method. Practically, however, the Kuna woman’s groups were fervently opposed to chlorination because they considered chlorine a powerful bleaching agent capable of making the kids’ clothes sparkling white.

Ida, an important member of a woman’s group on Ustupu

Melvin and the aqueduct committee were hesitant too because of the practice of using chlorine to dislodge octopuses from surrounding reefs. Harvesting octopus is dramatically easier if a small amount of the chemical is added to the sea-water surrounding an octopus. On Ustupu, men are commonly seen with a spear full of octopus in one hand, and a little bottle of chlorine in the other. As a result of these cultural practices, the idea of drinking anything with chlorine in it was met with great opposition.

The next alternative focused on water purification at the household rather than at the municipal level. Most Kuna were well aware of boiling but rarely adopted it. While boiling would purify the water, there was no reasonable economical source of fuel. The Kuna live on the island but travel daily to the mainland to farm. Bringing firewood to the island meant bringing home less food.

Harvesting plantain from the mainland

No rational woman would trade food for safe water. We were left with no practical solution for decontaminating the water.

Months later, Melvin and I learned of the possibility of solar water purification. We first heard of this technique at a sustainable technologies seminar in another region of Panama. The dissemination of crucial information is very slow on Ustupu because one does not have access to libraries, the Internet, or, generally, experts. The limited flow of information to Ustupu was in many ways as problematic as the flow of water. Peace Corps volunteers can be useful information brokers by bridging information gaps and communicating new technologies, even very rudimentary ones.

Explaining solar water purification to a group of water technicians at a seminar in the neighboring community of Ucupseni, Kuna Yala

Solar purification is a very simple process; a transparent two-liter soda bottle is filled with water, the top is closed, and the bottle is placed in the sun for 6 hours. The heat and UV radiation kill the contaminating organisms and make the water safe to drink.

Regardless of Melvin’s stature in the community and my supporting role, there was an intellectual resistance to the idea that the existing system needed fixing. People were often perplexed by the idea that the current system, built for them by government engineers from Panama City, could make them sick. Although I could not see the biological organisms in the water, I knew they existed. I came to realize that my knowledge of these organisms was not intuitive, but really dated back to when I was a child experimenting with a microscope in science class. I recalled from biology classes in high school the story of Leeuwenhoek’s surprise in the 17th century when he first looked at water with a microscope. During our Peace Corps training, we were taught about techniques used to purify contaminated water and the sources of contamination, and our instructors assumed that we would not question the fact that the organisms were there in the first place.

As I went from house to house excitedly talking about this new solar technique, I noticed a familiar look on the faces of the Kuna. For people in the village, the existence of the organisms was not intuitive, just like it had not been for me until I saw them under the microscope. Without a microscope to be found on the island, few people had ever seen anything on the microscopic level. I knew that many people believed there were harmful organisms even in water that appeared clear, but without having seen them for themselves, there was a definite lack of enthusiasm for solar disinfection.

On my next trip out of Ustupu, I was able to get an old microscope and returned with it to the village. The response was unbelievable! One look at a sample of river water, especially after a heavy rain, and the villagers now had a visual image when Melvin and I spoke of microscopic organisms and “dirty” water. The glass of water that I would hold up had the same clear, clean looking appearance as before, but after looking through the microscope there was increased validity and understanding that the “dirtiness” existed beyond what the eye could see. Mothers took ownership of the project, making sure that they had sufficient supplies of plastic bottles laid out on their thatch-roofs for everyone in the family.

Unlike boiling and chlorination, the solar water purification method was acceptable to the Kuna community because it did not conflict with cultural practices on the island. Men were not being asked to expend time and energy to bring back additional wood for fuel to boil water, and women did not need to set aside their objections to chlorination. All three methods are technically feasible, but only solar purification was culturally acceptable, making it the most sustainable solution.

While I was helping on the plantain field, Melvin once commented on why he thought the solar purification method was viewed positively. The Kuna, well acquainted with the powerful tropical sun, seek shade during midday hours, when the suns rays are most powerful. Therefore, especially with the visual provided by the microscope, it made sense that the sun could kill the microorganisms in the water. Making solar purification increasingly workable for the Kuna was the fact that plastic bottles, the only equipment needed, were cheap and available from passing merchant ships.

Passing merchant ship

In a subsistence agricultural community like Ustupu, where the monetary unit is often still the coconut (worth 5 cents each), solar purification demonstrates that appropriate health interventions and the health of the community can be attained at low cost. Ideally, Melvin and other community leaders want a functioning aqueduct system, but in the meantime, they view solar purification as a viable substitute.

Living in the community of Ustupu as a Peace Corps volunteer for two years revealed the complex problems surrounding contaminated drinking water. It also revealed that appropriate solutions can be found. It is likely that this method of water purification can be sustained over time. As we have seen here, understanding local knowledge and practices is essential. Indigenous leaders like Melvin apply local knowledge to specific problems, in this case water purification. Grass roots health education is also very important, of course, as a means to make information available in the community. It is possible to prevent water-borne diseases given the right combination of infrastructure, cultural sensitivity, and local leadership.

Acknowledgement
Thanks to Sam Halperin, my brother, for help with the two sand filtration computer renderings.

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Matt Bonds and Max Fraden

Abstract
Matt Bonds and Max Fraden document their experience unrolling a health insurance subsidization scheme in the Millennium Village in Mayenge, Rwanda. The Millennium Villages Project aims to achieve the eight Millennium Development Goals. These goals outline a global partnership to reduce extreme poverty with specific focuses on hunger, education, gender equality, health, and environmental sustainability. Matt and Max comment on critical lessons learned and observations on the field of sustainable development from their work in Rwanda.

Part I: Matt Bonds

A Note on the Millennium Villages Project: Rwanda

Millennium Villages sites across Sub-Saharan Africa

The Millennium Villages Project aims to achieve the eight Millennium Development Goals. These goals outline a global partnership to reduce extreme poverty with a specific focus on hunger, education, gender equality, health, and environmental sustainability.

Mayange Sector, one of the poorest regions in Rwanda (with an average annual income of under 150 US dollars), is home to 4,600 households and approximately 25,000 people. The Government of Rwanda (GoR) selected Mayange in 2005 as a Millennium Village, making it the third such site in Africa.

Unlike most of rural Rwanda where individual homesteads are scattered across the hilly landscape, Mayange has several umudugudus – also known as settlements – of closely spaced dwellings. The government built these settlements after the 1994 genocide in order to house returnees. Within the sector are five primary schools, one secondary school, one health center, and over 2,300 hectares of farmland cultivated during the 2007 long rains.

Aerial map of Rwanda: The red X indicates the Rwandan Millennium Village

Breaking the Disease-Driven Poverty Trap

One out of six people in the world today suffers from extreme poverty (UN Millennium Project, 2005). This kind of poverty means barely enough economic productivity to survive, leaving little or nothing to invest for the future. Such a dearth of savings and investment has translated to one of the most puzzling realizations of our time: significant portions of the globe have never experienced meaningful economic growth and are roughly as poor today as they were tens of thousands of years ago.

That the developed world has largely ignored these problems should put a blemish on our collective conscience. Perhaps the issues have been too abstract and confusing to seem real or soluble. But the ever-growing rift between the rich and poor is something that more and more people of the rich world are finding unacceptable. The Millennium Villages Project (MVP) serves to provide something of a remedy to this. Through a suite of basic interventions in agriculture and land management, health, education, infrastructure, family planning, and business development, the MVP works with local communities and national governments to offer a comprehensive economic development package which strives to eliminate extreme poverty in rural Africa. It also offers an opportunity for people of the rich world to work in solidarity with those of the poor world, helping to dismantle not just the economic issues at play, but also a sense of social disconnection between the two worlds. As an economist and disease ecologist trained in the U.S., my introduction to the practical side of international development has come formally through my position as an Earth Institute Postdoctoral Fellow working with the MVP in Rwanda, and informally through my friendships with Rwandans on the MVP staff and from the villages themselves.

If there is a single lesson I’ve learned from working on the ground with the MVP, it is that the problems addressed by the sustainable development community (disease, conflict, population growth, land and water scarcity, etc.) take a lot of intellectual work to comprehend in the West, but are often devastatingly obvious in much of the poor world. Certain debates (like those over trade-offs between economic growth and environmental conservation that pit economists against ecologists in the U.S., for example, or those over whether population growth is economically good or bad) can be highly misguided and often falsely dichotomous when applied to underdeveloped countries. In areas of extreme poverty, like parts of Rwanda, where nearly the entire population subsists directly off of its finite land holdings, economics is clearly driven by the relationships between people and their environment. People rely on fertile soils and reliable sources of water, while human population growth necessarily increases per capita consumption of resources. Aside from resource conservation and management, a critical part of the solution is a more diverse set of inputs (facilitated by free markets and trade), which is a paradigm too often decried as neo-liberal ideology. The most fundamentally important resource of all that social, political, and natural scientists of many stripes can agree on is healthy labor. This makes basic healthcare a particularly high priority for sustainable economic development.

In describing my experience with the Rwanda MVP, I want to emphasize two points: 1) the leading killer in Rwanda is not violence, it is disease; and 2) violence and disease are both products of the same problem: poverty. A small landlocked country of approximately 9 million people, Rwanda is the most densely-populated country in Africa, and over 50 percent of its population suffers from extreme poverty. Most people now know of Rwanda from the genocide of 1994, when approximately 800,000 Tutsis and Tutsi-sympathizers were systematically massacred by the Rwandan army and the civilian Hutu population over the course of three and a half months. The signature of the genocide remains everywhere in the country, as in the weekly local tribunals for genocide or the many genocide resettlement communities. It is especially significant in the Nyamata and Mayange sectors where the MVP operates; each sector lost 60 percent of its population in 1994. When the project began in December of 2005, the life-expectancy at birth in Nyamata was 39 years, and the under-five mortality rate was 23.3 percent. Many people are especially concerned by the effects on the community of the genocide as well as its underlying causes, along with how that concern affects our work.

When I first arrived in Nyamata in February of 2007, a year after the project was off the ground, I began working with Max Fraden on determining health insurance subsidies for every household in Nyamata. Of all the MVP interventions, basic universal healthcare is the most fundamental and least expensive, and therefore has the greatest “return on investment.” The leading cause of death for Rwandans, and indeed throughout Africa, is not conflict, but highly preventable and treatable infectious diseases. Therefore, the MVP specifically focuses on healthcare access. For example, the MVP improved quality of healthcare in a clinic by increasing the nursing staff, building an inventory of drugs, and expanding health services.

Before the MVP arrived in Mayange, the area health clinic was often out of service due to the circular problems of a lack of resources for treating illness and a lack of faith in the hypothetical service itself; the staff was indeed often known to “work from home” because residents rarely used the clinic, while the residents rarely used the clinic because it was often closed. Increasing healthcare access therefore requires a process of building faith in the health system in addition to adequately efficient health services. Given that early treatment of disease is critical not only for preventing the development of complications, but also for preventing further transmission, the community and the country have an interest in ensuring that each individual is treated quickly when symptoms arise. The government of Rwanda has accordingly required Rwandans to buy into the health insurance program called Mutuelle. To encourage participation in the health system, and to complement the positive impacts of greater food production, the MVP requires residents to purchase Mutuelle in order to qualify for seed and fertilizer loans. Mutuelle is priced at about 2 U.S. dollars per person per year, which can be prohibitively expensive in an area where subsistence farmers with little or no cash income comprise 90 percent of the population. Therefore, the MVP subsidizes the program based on need.

Our task was to determine appropriate Mutuelle subsidies based on a socioeconomic index of the population by creating a cheap, easy, and scalable method. In practice, this meant that we needed to determine key household indicators of economic status that were measurable with a quick survey and that we could analyze with packaged statistical techniques to which others in Rwanda would have access. After preliminary research, we began with a series of informal household interviews with residents from across income strata to inform our survey design. Our translator was Delphin Muhizi, an MVP community mobilizer and now a good friend of mine. Like many of our staff, Delphin is around 30 years old and spent his early years outside of the country. He went to primary and secondary school in the Democratic Republic of the Congo before returning to Rwanda after the war in 1994. He recently completed his bachelor’s degree on demography and land policy, and has a particular passion for improving food production. English is his fourth language, and he has a gift for approaching community members, putting them at ease, and asking questions respectfully.

Delphin first took us to a “typical” representative of the poorest residents. She was a 50 year old woman sitting barefoot and topless behind her one-room, mud-brick, thatched-roof house that sat upon a small hill that overlooked a breathtaking mountainous landscape. We sat on a bench outside her home in the mid afternoon and conversed as her family and many grandchildren soon convened around us, very curious about the white visitors, “umuzungus.” Our questions focused on how they survived, how they generated income, what their priorities were, what they owned, and what they felt they lacked. They owned almost nothing, and even rented land for cultivation. An increase in income to them, they said, would mean owning land, and obtaining goats, a cow, a mattress, and improved mortar for the frame of their door, which wouldn’t close. I remember being struck by how relaxed, pleasant, and positive this encounter was, given that we were there to explore understand the needs of the poorest of the poor.

Delphin then took us to a “middle income” home. On MVP motorcycles, we drove to a small village neighborhood, “umudugudu,” via a short main street lined with a row of houses, and approached a young woman in her mid-twenties. Her home was mud-brick with a concrete façade that from the outside, looked to be a clear improvement from the previous house. The song of a solo female vocalist emanated from a radio in her dark living room, as we all sat on a single bench, observing the bare walls and dirt floor of the bare room. She explained that she was orphaned during the genocide, that she inherited two hectares (five acres) of land that were more than she could manage alone, that she had two children, and that her relatively nice home was provided by an NGO that worked for genocide survivors. In contrast to the first interviewee, who was older, vital, and warm, this second woman was much more subdued. We then talked to a nearby couple, who appeared to be a bit wealthier, as indicated by the cow in their front yard. They were an older pair who had lost their children during the genocide and adopted an orphan since. They were extremely warm and gentle and seemed happy to talk. They explained that the cow was actually owned by their adopted child. They wanted bank credit, so they could buy some more land to farm and another cow for milk.

Over time, our informal conversations led to a short household survey on ownership of a collection of household assets (i.e., table, bench, mattress, radio, etc.) that we used to determine eligibility for health insurance. Through help from MVP staff and the community, we eventually surveyed all households (~4500) in Nyamata. We analyzed the data with a pattern recognition technique called principle components analysis, and correlated the results with previous ownership of health insurance. We then were able to determine how these assets indicated ability to pay for coverage, and determined subsidies designed to achieve universal coverage based on our index.

Other major health research questions focused on the impact of MVP policies, such as expanding Mutuelle coverage, distributing malaria bed nets, removing clinic fees, expanding health satellite posts, and hiring community health workers. The necessary data is collected through other surveys or through health clinic records, and we are currently synthesizing these analyses for further publication.

For the MVP in Rwanda, my role has been unique in that I am one of the only people whose primary role has been to observe policy rather than execute it. How strange and relieving it was to arrive in Rwanda, after being saturated with scientific literature, sensing that, at the outset, just about everybody knew more about the issues than I did. The single most important economic variable on the minds of our staff and of the residents of Nyamata and Mayange was something one did not need a Ph.D. to understand. It was whether the rains would be generous that season. Every week after I returned to the U.S. last spring, Max or Delphin would send notice on the status of the rains, which failed. Poor rains combined with a virus that thrives under drought conditions meant wide-scale crop failure in Mayange. Consequently, the MVP had to forgive many of the seed and fertilizer loans, a frustrating reminder of the difficulties of working in these environments. Fortunately, through improved seed, fertilizer and training in planting techniques, the previous season witnessed a quadrupling of typical harvests, which offered some buffer against future crop failure. Further, because of near-universal healthcare access and bed net coverage, there were no funerals in Mayange that season.

To the typical (Western) lay-reader, Rwanda’s conflict, poverty, and disease may seem like a depressing version of a familiar African story. In the midst of an unpredictable and unforgiving environment, where the stakes of failed policy are so high, one would expect the working environment of the MVP to be correspondingly unforgiving. In a sense, it is. But what I found is that such destitution and utterly serious humanitarian challenges are in the context of a very rich and vibrant social context. As one who has explored these problems indoors through academic lenses an ocean away, what I have felt from these experiences is a kind of moral or visceral release. Working on these kinds of problems in collaboration with the community, the Rwandan staff, our director, Josh Ruxin, and others like Max and our health coordinator, Ranu Dhillon, feels like a privilege even under the worst circumstances. Seeing such work and sacrifice not for each other, but for a common critically important purpose, is inspiring. It is also a privilege to understand extreme poverty outside of the contexts of sympathy and guilt. I admire those like Delphin and the community at large for their focused orientation towards progress.

Last July, I returned with Delphin to one of the first houses we visited, that of the 20-something who had been orphaned, to drop off a photograph. The woman remembered us immediately and greeted us warmly. Delphin did not hesitate to question her about the progress of her kitchen garden. Afterwards, he looked at me with a bit of frustration, but with a truly inspiring sense of determination, and said, “This is my goal Matt. Every Rwandan must have a productive kitchen garden.”

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