Sunday, May 31, 2015

On being a good tourist in poor parts of the world!

Hello friends! 

So, I have been keeping a list entitled things to do in Brazil. Every time someone suggests a restaurant, a club, a museum and a food that I should absolutely try while I am here, I whip out my phone and record it! There is one thing I am NOT going to do though.
my Brazil bucket list!

I will not go on a favela tour in Rio de Janeiro.

One of my favorite Internet phenomena of the past year has been a tumblr called “Gurl Goes to Africa.” This blog was a collection of Facebook pictures of “white girls” who went to visit in Africa, for whatever reason, and took these pictures with the “ locals” that they captioned with things like, “These African babies are so much lighter than American babies” and their family and friends commented “ Aww honey we are so proud of you, putting a smile on the faces of these poor African kids.” The onion, America's finest news source summed it up well with the article, “ 6-Day Visit To Rural African Village Completely Changes Woman’s Facebook Profile Picture”.  This blog went viral with criticisms arising from trivial things like why he chose to highlight only girls and more interestingly it sparked a debate on the ethics of volunteerism/voluntourism in poor parts of the world and personal photo journalism that comes with it, including practices such as slum tourism.

If you are not familiar with it, slum tourism is a type of tourism that involves visiting impoverished areas that was originally focused on the slums of London and Manhattan in the 19th Century (thanks wikipedia). "Now, from the favelas of Rio de Janeiro to the townships of Johannesburg to the garbage dumps of Mexico, tourists are forsaking, at least for a while, beaches and museums for crowded, dirty — and in many ways surprising — slums" (direct quote from some article praising slum tourism). Wait, can we take a moment to recognize that early slum tourism was in Manhattan??? Thank you, you may all take your seats now.

Slum tourism is a divisive subject and I have so much to say on it. I worked on this article for two weeks just to try to be as concise as possible. It still ran long but I promise you it is good read, so here goes.

 One school of thought calls slum tourism a clever way of raising awareness of social conditions and poverty to people who would otherwise never know about it. In the 1980s in South Africa, in an attempt to bring global attention to gross human rights violations occurring due to apartheid, black residents brought slum tourism onto themselves, by organizing township tours to educate the whites in local governments and the world about the racially segregated, impoverished districts they were being forced to live in. In that same line of reasoning, to conquer the perception of slum residents as helpless in their situation, Dharavi Tours in India aims to showcase the Dharavi slum in Mumbai as the heart of small-scale industry in the city. Visitors on this tour experience a wide range of economic activities including recycling, pottery making, embroidery, baking, soap-making, leather tanning, poppadom making and many more. In her article, The End of the Developing World, Dayo Olopade wrote about how poor people live in the optimal space of solutions and are entrepreneurs by necessity, because they have to come up with solutions to survive everyday. She even went on to claim a thing or 2 about sustainability could be learnt from these “lean” economies by the “fat” economies of the west, which would a great outcome of slum tourism if ever. As an added bonus some slum tour companies claim to be ploughing back some of their profits to the slum communities they showcase, an arguable point. I mean if they do improve the slums, they will be out of job right?  

The other school of thought is where I stand. Slum tourism at its core is a form of exploitation of the poor and their situation and stories without their explicit permission. Let me set this picture for you.

Some of my African friends and I have a running joke for years now. You know the hungry looking kids in some NGO commercials and brochures, we totally think we could have made the cut.  

I grew up in a middle-income family in a modest neighborhood in Zimbabwe. I was a normal kid whose daily routine after school was change, eat, do my homework and go out to play with my best friend Brenda and other kids on my street. My mother insisted I wear my worn out clothes for these afternoon exploits because I came back home, shoeless,  looking like a little ghost from top to bottom with red clay-caked feet, from running around on the street in the dirt all day.  Two things were a wonder to us growing up, great big cars and white people. They were such a rare sight in our neighborhood that we ran after them in awe if we ever saw one on our street. I do not remember if this ever happened to me, but if any of them ever had a camera, Brenda and I would probably put on these wide toothed smiles and jostle each other to be in the front of a picture.  

The Internet is rife with such images; these smiling kids who have no idea what having their picture taken like that means or where it is going. These pictures are the reason why when I got to college, one of the questions I got from my curious classmates, was “Oh you are from Africa, how does it feel wearing shoes???”  More importantly these kids have no idea what stories are being told about them. My first introduction to one of my favorite writers to date, Chimamanda Adichie, was through a TED talk called The Danger of a Single Story.  It’s a summary of how most of us insist on one lens of looking at the world, and we like to box things and people, especially when they are unfamiliar. The captions on the pictures on “Gurl goes to Africa” tell a story of privilege and people using it intentionally or not to tell other people’s stories who cannot defend themselves. No matter how good the intentions are, the fact of the matter is the poor are often victims in this power  because they do not in turn have a platform to express themselves after all is said and done.

All this is not to say there are no people without food, shelter, and basic commodities and services in Africa, India, and Brazil. They are there, just like there are very poor people in similar conditions in Detroit, Chicago and DC. There are ways of helping them, and snapping pictures of people in these situation and and captioning it, “Look, this is called a camera! I don’t know if you have these in Africa…” is not one of those ways.

For whatever reason people go on slum tours, slum tourism at its core effectively turns poverty into a spectacle and entertainment that can be momentarily experienced and then escaped from.  Aside from snapping away at the sight of a half dressed kid in front of a tin house, most of the time the visitors barely interact with residents of slums. Kennedy Odede, a Kenyan who grew up in the Kibera slums in Nairobi, wrote about seeing a group of tourists enter the home of a young woman giving birth in his home in Kibera. They stood and watched as she screamed. Eventually the group continued on its tour, cameras loaded with images of a woman in pain.

What did they learn? 
I can guarantee you they did not chat about the state of healthcare in Kenya and the World Health Organization’s MDG goals of fighting martenal mortality by educating populations about the dangers of births in non sterile conditions, or the cultural significance of a home birth in some parts of Africa, or the role of midwives in these situations, I could go on and on. Perhaps I am too cynical they did, but for like all of 30 seconds, and the rest of the time, they were feeling damn lucky it is not them.

And did the woman gain anything from the experience?  I will leave that to you, dear audience.

My last note, people in extreme poverty exist largely because of the failings of socio-economic and political systems to protect them and provide them with the means and opportunities to get out of these situations. Slum tourism is a display of government failure, and I will never get how governments allow this to occur at all.  Well in Zimbabwe, my government once tried to hide its failures in one Operation Murambatsvina/ Drive out Rubbish, where up to 700,000 people were displaced in what the government called a crackdown on illegal housing. There is an argument that people are poor because they want to be, which is totally not warranted. In a graduation speech a few weeks, Neil Degrassi Tyson said, “We live in a world where not everyone has the urge to help others. ... It is OK to encourage others to pull themselves up by the bootstraps. But if you do, just remember that some people have no boots. ”They have no boots and barely a voice to defend themselves when accosted with this depiction of their stories." 

So dear friends, please be good and responsible tourists in poor countries. Think twice before you take a close up picture of the family begging on the streets in Ethiopia, or people picking garbage in Mexico or half dressed children in Rio. They may smile for the camera but you as a person in a position of power should know better than to exploit their image and their circumstances in such a away. Go on your favela tour and get whatever satisfaction you get from it but remember to be respectful of people’s situations and their stories when you document your visit.  Or better just don’t do it, it's in bad taste. 

Now for the big finish, remember Kennedy Odede’s words on Kibera slum tourists, 

“They get a picture, we lose a piece of our dignity.”

Because I had no images to depict this matter that is close to my heart, I will just accost you with a picture of me in front of an awesome graffiti wall in Liberdade, the Japan town of Sao Paulo.  I am still investigating the artwork in this city.
I had to do it! 
 

Wednesday, May 27, 2015

When in Rome...

In the two weeks that I have been in South Africa, without any exaggeration, every other person is training for a long-distance endurance event.  A PATH colleague will be running his tenth 90 km/56 mi ultra-marathon next weekend, while people I met in Cape Town were participating in a several-hundred kilometer cycling event.

A friend of mine introduced me to her South African friend that lives in Johannesburg and she invited me to join in on a hike with a group of friends this past weekend.  After hearing about everyone’s active lifestyles for the past two weeks, I decided to go ahead even though I knew the distance and terrain was slightly out of my fitness league.

I was in the company of ultra-marathoners, people training for a 500 km adventure race in Swaziland, people for whom running marathons didn’t require much thought or training, and people who couldn’t fit their overdeveloped calves and quads into regular sized jeans.  What could have been a weekend surrounded by intimidating people turned out to be a really good hike, getting to know fun people over an extended post-hike braai (barbecue), some nighttime milky-way gazing, and some much needed lazing in the sun.

The fitness and outdoor culture that is so prevalent among the people I have been meeting is amazing.  I really hope the inspiration and motivation I am feeling right now stays long beyond my time in proverbial Rome.

Num-Num trail in Mpumalanga (one of SA's nine provinces)
 

Tuesday, May 26, 2015

Life in the Haor

For two weeks now I have been field-based in Sunamganj, where the CARE-GSK Community Health Worker Initiative operates. This is a remote district in the northeast and about a seven-hour bus ride from Dhaka. It has the highest maternal and infant mortality rates in the country, with only 25% of births attended by a skilled provider. I will be here for the next couple months to carry out my project.

Here is a small collection of thoughts from the past couple weeks.

On air.
My take on the Haystacks
It has been a smooth re-entry into the familiar airs of my beautiful subcontinent. Although remote, there is a purity here that is lost in the city. The air is fresh so I am breathing deeper but holding my breath through the fish market.

Singing and working
I have made all necessary adjustments to take care of myself. I have arranged for vegetarian meals of rice with vegetables. I set up a clothesline to air my clothes. I have sprayed everything with mosquito repellent. My WDI flashlight stays by my bed for frequent load shedding.

No complaints to air.

On water.
Cattle herding
Sunamganj is a haor area, meaning wetlands. Water flows down from the Meghalaya hills to fill this region. There are low-lying bodies of water everywhere, dividing the land into millions of island-like portions. Traveling often includes a boat.

The monsoon season will hit soon. Although I am no stranger to this, I am bracing myself for the especially powerful rains that will submerge most of the region. I recall my interview in which I was asked, “Can you swim?” Hopefully this will not be necessary.


Main mode of transport
Although crucial to the fishing and farming lifestyle, the water presents a unique challenge of isolation. In Sunamganj, access to health services and communication is sparse, resulting in devastating health consequences. I have heard stories of women in labor being carried in fishnets and by boat just to receive untimely help.

It is heartache to see this. I will have to do lots of thinking on how to make peace with the water.
 

On fieldwork.
Stomping the rice
This is the harvest season. Farmers are busy all day in the fields collecting their precious crops before the monsoon rains wash it away. They are the hardest workers for a most foundational output, sustenance. So much is put towards even grains of rice, as they are stomped, sifted, husked, and bagged. I am eating more consciously as I see this work around me. I am also aspiring to their work ethic.

Demoing scale for birthweight
My “fieldwork” has begun too. I have developed a survey to assess threats to service delivery in the current P-CSBA system and completed the pretest. I have observed performance reviews, skill labs, and ANCs. I have listened to P-CSBAs, Program Officers, Field Trainers, mothers, and local government members. I have traveled by car, boat, CNG, cycle rickshaw, and foot. My understanding grows daily as I learn the nuances of health delivery here.


Looking forward to posting an update after surveying! I will have seen more of this region and met some great people by then.

Friday, May 22, 2015

The Last Word

When I visited Cape Town several years ago with my family I remember thinking to myself that I would love to live in or, at the very least, revisit the city.  Who knew that I would get another opportunity to visit 13 years later.

My manager who works at Path’s Seattle headquarters flew with me to Cape Town for the first week of meetings and introductions.  Here I met Hlahla, who works at Path’s Johannesburg office and Aditya, a Public Health Masters student from Duke who is answering the policy related questions about how to influence Government and other key opinions leaders to adopt these technologies into national guidelines.

Supposedly a bed and breakfast, the hotel we stayed at in Constantia (a suburb of Cape Town) was the best I have ever stayed in with the most enormous rooms I have ever seen.  The bed (room) would have been the best part of the stay if the breakfast wasn’t as good as it was. 

Croissant French toast


Even though afternoons were filled with acronyms, the evenings were reserved for fun team outings.  Each night we ate dinner at a different place around the city and tried out different South African wines.  Dinners were sometimes preceded by walks around the waterfront, 10k team runs, or wine tasting at vineyards older than the U.S.  It was a great week and a fun way to get to know everyone.

Quick pit-stop for a team picture against the Atlantic Ocean
Over the weekend, I went shark cage diving! It was a long 12 hour day (a 2.5 hour drive each way) but extremely worth it.  Seeing 15 feet long great white sharks swim by 2-3 inches from my face was jaw dropping (pun intended).

But, my trip to the Kirstenbosch Botanical Gardens the next day was equally breathtaking.  Right at the foot of Table Mountain, the garden had huge open grasslands and great hiking routes trailing the base of the mountain.  After walking around the trails without a map for a couple hours I decided to find my way back to the entrance and not miss my flight to Johannesburg.

Approaching the trails at Kirstenbosch

Cape Town’s rugged mountains, dramatic ocean-facing mountain roadways, beautiful blue skies, and rolling vineyards got the last word – they’re going to force me to go back a third time. 

Wednesday, May 20, 2015

Acronym-filled afternoons

POPI, EMS, EMI, MRC, GHIA, DOH, WCBS, SANLS, M&E, SAMED, MCC and at least 15 other acronyms filled a large portion of my first week of work in Cape Town.  The project I am working on for Path is to develop a market entry/commercialization strategy for two low-cost health technologies for public and private sector markets in South Africa, Ghana, and Uganda.  This will include things such as demand forecasting, market segmentation, pricing, distribution, and understanding the process of selling to the Government - a perfect set of topics to explore for an MBA student. 

Path is funding local for-profit start-ups and SMEs (acronym!) for initial product development and commercialization with the hopes that after some initial hand-holding the companies could attract VC funding or become self-sustaining by the cash flows they generate. 

Most of my first week was spent interacting with the owners of the start-ups to better understand the main questions they would like me to answer, but I also got an opportunity to understand prevalent testing and treatment practices by visiting community health clinics and hospitals that are run by the Government.  It’s been a steep (but fun) learning curve trying to understand the details of the devices, learn about competing technologies and practices, and piece together the structure of the South African health system. 

Decoding acronyms at the hotel
                                                        

Tuesday, May 19, 2015

In the Land of a Thousand Hills

…..  and so after months of planning, a hectic week of packing and endless moments daydreaming about it, I landed in Rwanda.

Delphine, the Country Director of the Ihangane Project, the organization I will be working with this summer was at the airport to pick me up and after a quick and friendly introduction we jumped on a car and started making our way to Ruli which sits high on the northern hills about 40kms from the capital.

As we drove out of Kigali I was struck by how dark and still the night was. Even though there were a couple of other cars on the road the night seemed to have a peacefulness to it that I found surprising. In retrospect this might have been my mind starting to relax after hours of airplanes and airports but nonetheless, in my mind my first impression of Rwanda will always have a magical quality to it.
I have often heard that a great way to put a restless baby to sleep will be to stick him in a car and drive around for a while. As a parent I can attest to the almost miraculous effects that this will have on a baby. As an adult I can attest to the dangers of drawing from this well too often – thanks to my dear parents, much like Pavlov’s dog, I have been trained to act a certain way and, for as far back as I can remember, I cannot stay awake in a moving vehicle.

This trait of mine is of particular nuisance when you have just arrived in an unknown country and your new host is making conversation. I pinched myself as hard and in as many places as I could but I could recognize the familiar unavoidable signs that I was about to lose consciousness.
 
I needn’t have worried.

Soon the car made a sharp turn and we started down a bumpy roller-coaster dirt road complete with sharp ninety degree turns, ravine near misses, fallen tree obstacles and small village check points. Did I mention we had Rwanda’s version of Evel Knievel at the wheel?

This was a little over a week ago. Since then I have developed a new appreciation for the ups and downs we had to cross in order to get here. The view from most anywhere in Ruli is of sprawling hills that twist and bend in many shades of green. The clouds are a constant companion for the many different birds and insects that you can see or hear in an otherwise pure blue sky. My favorite is peering out of my window to see the thunder when it is about to rain (or when the sky is about to come down since that is what night rain here feels like) or seeing the morning clouds disperse between the hills in the morning.

As I discover my new surroundings I also learn to appreciate things from my everyday life back home which are considered a luxury here: tap water one can drink, hot showers in a none-squatting position and a reliable internet connection are among the most notable.

To be able to connect to the internet signal I have to stand outside, between the hospital administrative offices (where I get the connection from) and the row of smaller rooms where the Ihangane Project office is located. Far from being an irritation I actually enjoy the opportunity to sit and work outside, especially since I get to see people’s faces as they walk around and suddenly see this umuzungu, completely out of place, sitting on the floor desperately typing on his laptop. Kids are the best in this respect, they approach me, sit down next to me and, as they watch me work, start conversations that go on way past the point at which it becomes obvious that neither of us understands the other. Still, a smile is universal language right?

This week I also had the opportunity to go with JD and Dianne to the place where the porridge production facility is being built. We went up there on taxi bikes and walked down to the office on a path that wound through different small family plots in which maize, coffee, soy, sorghum, carrots and potatoes were growing. JD mentioned that these were the “back alleys” he used to hide in when he wanted to skip school but for me it was more akin to something out of a Peter Rabbit novel – amazing how the place we grow up in will shape the way we look at new environments.

The porridge production facility will be the core of my work the next following months as I work with the Ihangane Project to develop a business plan and strategy to make fortified porridge production for HIV+ mothers and children a sustainable business. So far I have gotten a rough draft of some of the variable and fixed costs that they will face and an idea of what total output might look like, but, even though it is still early days, I get the feeling that the truly sustainable solution will lay in how to bring different stakeholders and members of the community together.

For now, I look forward to the following weeks in which I continue to learn from and explore this beautiful land.

Internship beginnings!

In the twenty-minute stretch from Dhaka International Airport to Gulshan Thana alone, the driver pointed out Save the Children, BRAC, UNFPA, UNICEF, ICDDR, WTO, DFID, Grameen Bank, CARE, GSK, and various country embassies - an overwhelming presence of international heavyweights in the form of offices, billboards, and marked vehicles. This silo of foreign relations leaks into the bustling markets, cottage industries, and traffic gridlock that is Dhaka. It is an interesting thought on a small country’s affinity for a large global investment and certainly an apt introduction as I engage in the global health field with CARE Bangladesh.
Fragrant jasmine flowers

My name is Surabhi Rajaram and I am pursuing an MPH in Health Behavior and Health Education at the School of Public Health.  I am a professional student with internships abroad as my limited insights into the “real” working world. This, in addition to an obsession with The Office, has probably skewed my understanding of the traditional workplace. I love it!

This summer, I am grateful to be joining the CARE-GSK Community Health Worker Initiative (CGCHWI). The initiative is part of GSK’s 20% reinvestment program to strengthen health systems through development of a skilled workforce. In a remote area of Bangladesh, female health workers called Private-Community Skilled Birth Attendants (P-CSBAs) are being trained and deployed to combat high rates of maternal and infant mortality.  My project this summer is to develop a sustainable and scalable business model for equitable healthcare delivery through this network of P-CSBA entrepreneurs.  I will be primarily field-based in the Sunamganj district with Dhaka bookending my stay.
Safe birthing kit

Thus far, my impressions of CARE BD Headquarters have been provoking. There is not enough to say for an organization that internalizes the core tenants it hopes to foster through its projects – women empowerment, dignity. As much as the workplace is filled with self-aware fathers of daughters, sons of mothers and brothers of sisters, it is filled with daughters, mothers, and sisters empowering themselves through work for their fellow people. The team brings a dignity to their work through compassion and mutual respect. I am thoroughly enjoying being called Surabhi Didi (sister) and welcomed not just as an intern, but as a member of the “family.” Looking forward to learning with this amazing team!

Stay tuned as I continue to share about my experiences this summer! And apologies for the embarrassing amount of acronyms.