Minga Blog: Evaluation—How we know when we’re contributing to social change

The world of development is lush with evaluation, a jungle of metrics and indicators meant to show how well the work is going and yet how much more we have to do. From dusk to dawn, the development worker must navigate this jungle, crafting monitoring and evaluation plans in project proposals, holding themselves accountable in weekly team meetings, tallying progress in interim reports, proudly reporting (or massaging) the numbers in final project documents, and then spinning it all into the perfect pitch in advertisements to potential donors.

This is a paradise for the bean-counting technocrats who thrive in this rich ecosystem of numbers, from basic inputs (the number of bed nets distributed, the number of nutritionally balanced meals donated, the number of refugees housed, the number of workshops run and the total participants) to complex outcomes (microbusinesses started and maintained for five years, families “lifted” out of food insecurity, increases in GDP or HDI).

And yet the rest of us might be forgiven if, tripping through this gnarly thicket of simple, observable, and measurable “indicators,” we ask, “but how are you actually making peoples lives better?” Or we say, “I know you’ve done a lot. And I know that x action led to y and z outcomes. But what really changed?” Because at the end of the day we do not aim to create a world full of bed nets or workshops or microbusinesses or high GDPs. We aim for a world that is changed, a world that is so radically changed that poverty, ill health, food insecurity, and exploitation cannot be created in the first place.

At Minga, we express this vision quite clearly in our mission: to build capacity for health and social change. But how do you evaluate that?

 Measuring whether we improve health is pretty straightforward. Tally the problems before and after, adjust for other influences, and there you go. So in our early work in Ecuador, for example, we can look at the extraordinarily high rates of malaria infection in the region of El Páramo before we began, the near-zero rates of malaria today, and we can be fairly confident that our efforts to distribute bed nets, provide local lab testing, secure access to treatment, and conduct culturally appropriate1 health education had a significant impact.

To some extent, it’s not much harder to evaluate whether we are building capacity for health. Just look at the infrastructure that we’ve put in place: health centers, laboratories, and medical staff; trained community health workers; boreholes and piping to ensure access to clean water; community gardens to enhance food security; etc. But capacity for health entails more than just the existence of health infrastructure. It also includes the ability of individuals and communities to identify risks, develop solutions, mobilize resources, secure assistance, etc. These more subtle impacts require much more nuanced evaluation. One way that we assess these more subtle aspects of community capacity for health is by examining changes in the ways that our partners describe their work, challenges, and goals. Did their analysis of community assets, problems, and responses change from the initial proposal to their final report? Did their experience with a Minga-funded project provide them with clear lessons? And are they putting these lessons into practice via new funding proposals, changes to their projects, revisions to their mission, etc.?

And that brings us to the most complex, but arguably the most important, aspect of our work—to build capacity for social change. Here we are talking not just measurable project outcomes, nor even lessons for health programming, but rather about developing forms of community power that actually challenge local patterns of exploitation and marginalization. To evaluate these impacts requires that we first understand what historical, cultural, political, and economic factors actually contribute to people’s marginalization. And then we have to look for changes.

Our work with BUVAD in Uganda provides a great example. As in many places, the small farmers of the Kayunga District are multiply marginalized. Their wellbeing and stability is affected by economic factors (small land holdings, limited ownership of agricultural technologies, and a low place on the commodity chain) and biological factors (limited access to clean water, in part because of colonial and post-colonial land use policies; thus long trips to wells and high burdens of water-borne illnesses). Addressing these issues—as most development work attempts to do—matters a great deal, but that alone is not sufficient to facilitate social change. We therefore also try to attend to socio-political factors (low levels of political influence, little attention from public servants, poor representation in policy realms). Thus, in our work with BUVAD and its fantastic executive director, Stephen, we not only provided funding for new wells but also set in motion a range of initiatives to change Kayunga’s political marginalization.

How do we know? These are some of the indicators we see:

  1. Increases in solidarity and a collective voice: Minga made a modest contribution to building national solidarity by bringing BUVAD into UWASNET, a network of NGOs working on water and sanitation issues. BUVAD is also building solidarity and self-governance at the local level via well governance committees.
  2. Increased influence over local policy: Experience with our project helped Stephen get onto the Kayunga District Water and Sanitation Committee, bolstering grassroots voices in local policy making.
  3. Access to data and education to support community demands and reduce stereotyping and the dismissal of “poor” rural people: Monitoring and evaluation work for our project equipped BUVAD with hard data that they can now bring to government officials to strengthen their demands for the fulfillment of basic infrastructure rights.
  4. Increasing autonomy so communities can not only affect the powerful but also thrive independently of them: Since working with us, Stephen has written successful grants to simultaneously boost local autonomy from those government officials and other outsiders via training for a local well mechanic and the installation of passive rainwater harvesting infrastructure.

These are all small changes, but collectively they begin to shift the dynamics that lead to people’s disempowerment in the first place. At Minga, we believe that the most significant and positive transformations will come when standard development is accompanied by this deeper socio-political work. That’s why, in each of our projects, we’re trying to figure out which factors really do build community capacity for social change—not to prove we’re great or insist that we’re still needed, but to figure out how to do this work better. We’ll continue to keep you posted!

1 – In this case, “culturally appropriate” is not just a “buzzword or fuzzword,” to quote Andrea Cornwall. Members of Minga (then Foundation Human Nature) and their international counterparts learned that people in El Páramo were not seeking biomedical attention for malaria because evil eye manifested with similar symptoms and, it was believed, consulting a medical doctor for evil eye could kill you. By carefully studying the differences in symptoms, our team was able to discern a difference in the timing of a malarial fever compared to an evil eye fever, and by teaching people to see the difference we helped get over this barrier to medical attention.

The Minga Bump

In politics, a ‘bump’ is a sudden increase in popularity for a candidate; due, for example, to receiving a key endorsement or attending a key event. The most commonly noted ‘bump’ in American politics is the ‘Convention Bump’: presidential candidates almost always receive a boost in popular support in the week(s) following their party’s national convention. More recently, talk show host Stephen Colbert coined the term ‘Colbert Bump’, a jump in support that candidates supposedly received for being guests on his program.

For over a decade, we at the Minga Foundation have been fine-tuning our approach to development work. At the same time, we’ve sought simple and transparent ways to communicate our basic vision and strategy. In this spirit, I would like to introduce the ‘Minga Bump’.

At our August, 2016 Board of Directors’ Meeting, Board Member and Minga co-founder Jessica Levy coined, extemporaneously, the expression ‘Minga Bump’. For a moment I thought she might be referring to an interpretive dance, which would somehow capture our essence as an organization (those of you who know Jessica will understand my brief hunch). Though to this day I haven’t given up on the dance idea, I quickly realized that Jessica was suggesting something else: that we appropriate the political concept of a ‘bump’, and use it to describe our model of development work.

The loss of a single individual, a single instance of human potential, to problems of under-development is tragic. A common refrain tells us that every individual child who dies before the age of 5 ‘could have been the one that cured cancer,’ and education policies are given titles such as ‘No Child Left Behind.’ We at Minga believe the same type of thinking should apply to community organizations.

Small, community-mobilizing organizations appear and disappear with frequency around the world. Indeed, a core subgroup of Minga Foundation Board members got to know one another as activists for Durham Congregations, Associations, and Neighborhoods (CAN), a local organizing group in Durham, North Carolina.

Unfortunately many such organizations, whether in the United States or sub-Saharan Africa, face problems of sustainability. After coming into existence based on the initial energy of an individual or a campaign, will these organizations have staying power? Will they be able to consolidate their achievements, and set their sights on new projects and goals? Or will they whither for lack of capacity and resources?

As with individuals, the loss of potential community- and world-changing organizations is tragic. As many of you know, ‘Minga’ is the Quechua word for ‘Community Action for a Common Cause’. Community mobilization is at the heart of our vision at the Minga Foundation. We believe that genuinely transformative development occurs through strong communities and advocacy networks; indeed, that the notion of development as an ‘external intervention’ is nearly a contradiction in terms. In turn, for us, the loss of a single community organization with strong mobilizing potential has a direct impact on community members’ well-being.

This problem is all the more pressing for the following reason: most of the most promising and newly forming community organizations around the world are missed by the larger donor agencies and foundations. They do not yet have the capacity to secure the support they need from domestic and international donors; and without that support they cannot develop the very capacity they lack. A catch-22 if I’ve ever seen one….

Enter the Minga Foundation. All of Minga’s projects are conducted in partnership with local organizations in our partner communities, from the Butakoola Village Association for Development; to the Nancholi Youth Organization; to the Lubengoa Women’s Development Association. We chose these organizations, and these projects, as part of a detailed application review process. And we chose them too because we found them to be promising, and at a stage in their development in which the ‘Minga Bump’ could be crucial.

Each of our projects involves the creation of a resource, whether a health clinic, a borehole well, or HIV/AIDS testing and education; but perhaps more importantly, this resource comes with a strategy for capacity-building. We seek to locate small but promising organizations around the world that the big players miss, and to provide their community members not only with an immediate good, but with an advocacy structure that is built to last. We help organizations which might otherwise perish not only survive, but grow, evolve, and consolidate. We give community organizations the ‘Minga Bump’, and our projects thus promote well-being in the immediate and medium-term.

Much more could be said, and problematized. Many ‘bumps’ in politics are ephemeral…the 5-point jump in the polls a candidate receives after his or her convention often quickly recedes, and the race normalizes. Obviously, this temporary and short-lived jolt is not what we’re after at Minga. We seek a truly meaningful boost, which puts in place organizations whose work and community imprint will still be recognizable in 10, 20, even 50 years. This is an immense challenge; and one that we accept and successfully face with enthusiasm and passion.

It’s an honor to be a part of this amazing group and this amazing work. And now, Jessica, how about that dance…?

Men, Masculinity & Violence

In this short piece, reprinted from the Society for Applied Anthropology newsletter,  Minga Foundation board member Karin Friederic and undergraduate student Adriana Cordova reflect on lessons learned while conducting workshops on gender violence in rural Ecuador last summer. They discuss both the successes and the limitations of educational interventions such as workshops on family relations and gender violence. These workshops were part of a broader project called “A Multipronged Approach to Combating Intimate-Partner Violence in Rural Coastal Ecuador” funded by the Feminist Review Trust.

“Si no le preparas comida a tu esposo, te pega, diga?”

“If you don’t cook food for your husband, he hits you, right?”

While spending two months in rural coastal Ecuador this summer, my student Adriana and I were asked this question on a couple different occasions by a precocious five-year old named Jeni. The little girl had noticed that I preferred cleaning dishes to preparing dinner. After many years of hearing these kinds of comments, I took the question in stride and responded that, no, my husband would not hit me because we always split the tasks of washing and cooking. But Adriana remained troubled, especially when Jeni asked her another time. She was especially concerned that Jeni might have learned this from watching her father beat her mother. Adriana got along really well with Jeni’s father, and could not imagine that he would lay a hand on his wife.

Though community members sometimes report that “violence no longer exists” and “all women here have rights now,” after fifteen years of conducting research on gender, violence, and community development in this region, I have grown accustomed to the slippages, contradictions, and the persistent ways that violence remains etched in everyday relations between men, women, and children (Friederic 2009, 2012). I didn’t actually think that Jeni’s father beat his wife. To be fair, I just didn’t know in this case. But I did know that narratives and threats of violence continue to be central to the making of masculinities and femininities in the region. I also knew that these messages were often circulated by women themselves, especially when they were raising and socializing their children. As it turns out, this is precisely how Jeni had learned this “truth.” Her mother later told Adriana that, even if not cooking might not result in violence in her household, it is well-known that cooking food for your husband is a wife’s moral duty. If a wife falters, she might get hit. Little girls should know this so they can prepare themselves accordingly and prevent problems in their future homes.

Adriana, a rising junior at Wake Forest University, accompanied me to rural Ecuador this summer to assist me with an intervention into gender violence and to conduct independent research on sexual health education in the local elementary and high schools. In this column, we reflect on the ways that we had to consistently remind ourselves and our interlocutors to challenge (and not reproduce) normalized assumptions about masculinity, sexuality, and violence, and the links between them. Adriana’s research revealed strictly-defined, naturalized gender norms that inadvertently shaped how she conducted her research. In my own project, workshops that I helped organize sometimes tended to reproduce the idea that men are inherently violent, leaving little room for the development of alternative masculinities.

Adriana’s Project: Health Education & Family Relations in Rural Ecuador

During the five weeks that I, Adriana, spent in rural coastal Ecuador this summer, I set out to find how parents and teachers in Ecuador perceive the quality and value of health education in public schools. At first, I had planned to ask about what people knew about health education, the curriculum, and how it should be improved. But soon after my arrival, I began to see how rigid gender norms were. When I recognized that there was severe gender inequality, I decided to make changes to my research. In the eleven interviews I conducted, I incorporated more questions to learn about how people perceived that sexual education should be different for young men and young women, and who they thought was responsible for doing the educating.

In these interviews, I often heard parents and teachers reproduce particular ideas about the differences between boys and girls and their roles, which corresponded to how they should learn about sex. According to most of the people I interviewed, girls should learn about sex from their mothers and boys should learn about sex from their fathers. But it also became clear that the way that girls and boys were meant to learn, and the ways that fathers and mothers were expected to teach them, was very different. For example, in many cases, boys learned about sex from their fathers by going to brothels, whereas girls would learn about sex through conversations with their mothers. But speaking about sex was a tricky issue. Mothers explained that they should talk openly to their children, yet at the same time, they thought that speaking about sex would automatically encourage girls, in particular, to start having sex. Teachers often told me that the reason why it was important to teach sexual education in school was because girls were running off and getting pregnant. Teachers and mothers knew that sexual education was important, but the mode of education was perceived differently. Both teachers and parents seemed much more concerned about girls than boys having sex at an early age.

Therefore, I noticed not only a strict division of labor between genders, but also sets of very different standards and expectations. As we saw with Jeni, this division begins at a very young age; girls like Jeni learn both by observing different gender norms in the household and by being told this is what happens. In a lot of the talk about health and sex education, it was implied that men were more violent and more sexual, and women were more passive. In one instance, one of the mothers I was friends with told me that STD’s were becoming more common. She said that if her husband was sleeping with other women, he better not get any STD’s and give them to her. She said this in a very serious tone. Not once did she say if this happened she would leave her husband, nor did she say it was bad for him to be sleeping with other women. It seemed that it was accepted that men have sexual needs and therefore they have the right to sleep around. The wife just didn’t want to get stuck with an STD, so it was up to her to take precautions. Because it is considered natural that men will more often act on their sexual motivations as compared to women, there are distinct norms and expectations for men and women which are evident even in the ways that young boys and girls are taught about sexual education. Girls and boys were taught about sexual education differently because it is thought that each have different relationships to their own sexuality: men have to learn to indulge their sexuality with the least harm possible, and women have to learn to protect themselves from men’s inherently sexual and violent natures. These ideas are not just reproduced through how sexual education is taught but also through the types of messages parents communicate with their kids that are based in gendered assumptions that link masculinity, sexuality and violence, for example. I discovered links with Karin’s intimate partner violence research in ways I had not thought about before starting this research. Looking back, I also realize that I would have approached my research differently had I recognized more clearly how these gender norms become naturalized. From the beginning, I decided to interview only mothers because people told me that fathers were not involved with their children’s education. Reflecting upon this now, I should have considered or given the men a chance to share their opinions and insight about sexual education in the household. I myself fell into believing and reproducing normalized assumptions about masculinity, associating them with work outside the home, rather than with their role as fathers, involved in their children’s lives.

Karin’s Project: Intimate Partner Violence in Rural Coastal Ecuador

In rural coastal Ecuador, human rights campaigns against domestic violence have introduced new ideas about gender, sexuality, and health over the last fifteen years. As I, Karin, have written about elsewhere, recent advances in knowledge of rights and access to state-based justice have offered powerful opportunities for some women in the region, but the empowering potential of these efforts is limited (and often squandered) by women’s continued social and economic vulnerability (Friederic 2012, 2013).  Many suffer from increased violence or attempt suicide when their newly discovered right to live free from violence conflicts with the lack of means to change their circumstances.

For this reason, in conjunction with my research on gender violence, I sought out and received funding from the Feminist Review Trust to implement a small-scale intervention to mitigate some of these effects. This multifaceted project involves educational, micro-economic, and infrastructure initiatives to encourage a more supportive and sustainable socioeconomic environment for men and women seeking to diminish intimate partner violence. For one component, I partnered with in-country gender specialists with experience working with men on questions of violence to conduct intensive full-day workshops on household communication, gender equality, and gender violence. With their help, my field assistants and I coordinated a series of full-day workshops with activities such as community mapping, mini-lectures, socio-dramas, children’s activities, and group painting and drawing. Over 120 people attended, and the workshops were hailed a great success. Participants reported that they accomplished important self-reflective work, learned practical take-home lessons, and had lots of fun at the same time.

After my field assistants, including Adriana, and I decompressed from the first of the workshops, we discussed how the facilitators did a fantastic job honing participants’ awareness of and sensitivity to how gender organizes and unfairly structures daily life by pointing out women’s invisible labor, for example. They were also successful at eliciting gender norms and people’s discomfort with the strictness of these norms. However, one aspect of these workshops left us uncomfortable. The workshop discussions had only allowed for the existence of one kind of man: an aggressive, violent, hyper-sexual, “machista” male. And our communal goal was to get rid of him. But, the problem was how. There was little room created in these conversations for acknowledging and exploring alternative masculinities that could replace the ubiquitous “machista” male.

The concept of “machismo” played a central role in the workshop discussions, but the idea itself was never placed under scrutiny, even if it was mentioned constantly by participants and facilitators as “the problem” that we needed to overcome. In this local context, “machismo” usually refers to a panoply of masculine behaviors (physical, psychological, social, and economic) that serve to demean and control women. But during the workshops, “machismo” seemed to stand in for the most egregious of these behaviors: wife-beating. And all men seemed to be referred to as machos.

At one point, various participants noted themselves that not all men are machista, and you could sense some resentment that all men were being painted with a single brush. While this wasn’t the facilitators intent (as they later assured us), the conversation tended to continually re-direct and re-construct the figure of men as perpetrators of various forms of violence against women. Thankfully, we were able to discuss this openly with the facilitators, and the next series of workshops improved. But it left me thinking about all the ways that we might also invariably reproduce the idea that men are inherently and “naturally” violent, even when we are seeking to destabilize this very norm. In my own workshops and conversations, I have used the figure of the “macho” to break the ice, poke fun, and register my solidarity with women who disapprove of these behaviors, while also demonstrating my knowledge of local cultural norms. And while these tactics might work well for raising awareness and encouraging conversation, as applied anthropologists it is especially important that we also incorporate strategies, or at least the space, for the building of alternative gendered identities. For example, I learned that I needed to pay closer attention to the fissures and cracks where these stereotypes broke down, the moments when men embodied contradictory postures in their lives, and use these to encourage new ideas of self and masculinity.

Conclusion

In this column, Adriana and I reflect not only on what we have learned about the links between gender, sexuality, and violence during this past summer’s research, but also on how we must take care to not reproduce certain norms even as we allow local cues to guide our research. Adriana only interviewed mothers about health education because everyone told her that mothers are the only family members who would know about their children’s experience learning about health and sexuality. She now acknowledges that perhaps she didn’t give men enough of a chance to demonstrate their involvement in their children’s lives. It is assumed by all that women “naturally” know their children better. On the other hand, Karin recognized that, in her workshops, continual references to men as machistas who beat their wives run the risk of overly associating masculinity with violence. If not addressed, this elision between masculinity and violence may result in either “emasculating” non-violent men on the one hand, or it might lead to false claims that “violence no longer exists” simply because men aren’t as machista (i.e. engaged in regular wife-beating) as they used to be. So, while Jeni’s father may not beat his wife, this does not imply that gender violence is over. Violence, whether physical, psychological or economic, continues to structure and shape gender relations. Jeni is becoming a woman who perhaps does not deserve to put up with male violence, but she is also learning how to be responsible and accountable for avoiding it. In this line-of-thinking, if men are naturally and helplessly hypersexual and violent, then women must spend their time learning how to protect themselves lest they be cast as irresponsible women who were “asking for it,” a phenomenon of unfair gendered accountability that has unfortunate parallels worldwide.

Authors: Karin Friederic (Assistant Professor, Anthropology, Wake Forest University) and Adriana Córdova (Undergraduate Student, Class of 2017, Wake Forest University)

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Choosing Wisely: Selecting Medical Missions With Lasting Impact

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PINCC Trainees in Pearl Lagoon, Nicaragua review flashcards with images of cervical pathology with PINCC volunteers during an afternoon teaching session.

As a family physician with a strong interest in international work and travel, I often contemplate how to best balance my personal goals and needs with those of the communities I serve.  I have a strong desire to serve internationally but with a full time job here in the U.S., I can only get away for 1-2 weeks at a time and must use my vacation time for any volunteer work.  Most medical professionals in the U.S. are in a similar situation to me and thus can only consider short volunteer stints if at all.  As a board member of The Minga Foundation, I am always searching for sustainable projects to work on.  However many medical projects that accept short-term volunteers are anything but sustainable.

There are numerous medical non-profit organizations that specialize in what many consider “medical tourism.”  These organizations send teams of volunteer physicians, nurses and support staff to an “underserved” community for several days or a few weeks, provide donated materials, see hundreds of patients, and then leave.  The volunteers have a great time during their travel, enjoy the experience of “roughing it” and leave feeling as though they have really helped people in need.  But what impact do these projects really have on the long-term health of a community?  It turns out that it depends greatly on the overall design of the project and the behind-the-scenes work between on-site visits.

Short term medical missions not only have the potential of leading to unsustainable health impacts, but can actually undermine the existing health systems of the communities they are meant to serve.  Most medical mission projects provide free care which may discourage patients from seeking care from existing health providers in the intervals between mission visits. Frequently there is a duplication of services provided on mission trips without coordination with the local health system.  The most irresponsible organizations may also bring donations of donated medications that may be expired, unavailable for patients to continue in their home-country or with instructions printed in a language they cannot read.

Projects that focus on improving the knowledge, skills or capacity of medical providers in the community being served are much more likely to lead to lasting health improvements than projects where care is provided by foreign volunteers only.  I recently had the pleasure of volunteering with one of many medical non-profit organizations that truly “got it right.”  Prevention International: No Cervical Cancer (PINCC) is a non-profit organization with a mission to “create sustainable programs that prevent cervical cancer by educating women, training medical personnel, and equipping facilities in developing countries, utilizing proven, low cost, accessible technology methods.”  Though their volunteer model relies on 1-3 week international trips by American or Canadian providers, their work leads to completely sustainable change and has truly saved the lives of hundreds of women.  Knowing this makes the experience of volunteering with them even more gratifying.

PINCC was founded in 2005 by an OB/GYN in the San Francisco Bay Area, Dr Kay Taylor, whose vision was to help eliminate cervical cancer in developing countries where it is a leading cause of death for reproductive aged women.  Thanks to cervical cancer screening programs that emerged in the past century (PAP smears), cervical cancer is now incredibly rare in the United States and other developed countries. PAP smears allow providers to diagnose pre-cancerous changes in the cervix that can be easily treated years before they become cancer.  Cervical cancer is one of the most easily prevented diseases in modern medicine, yet requires a universally available screening program and access to treatment for women whose screening tests are abnormal.  Poorly organized and underfunded health systems, poor health care access for women in rural areas, and cultural stigma are just a few reasons why cervical cancer screening programs have not been as successful in many developing countries.  HIV infection increases a women’s risk of getting cervical cancer and so countries with high HIV infection rates have also seen huge increases in deaths from cervical cancer.

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Nurses in Muhoroni, Kenya reviewing their training manual in preparation for the day’s screening exams.

I recently volunteered with PINCC for one week in Muhoroni, a remote village in Western Kenya, and then another two weeks along the remote Caribbean Coast of Nicaragua.  During my time with PINCC I was constantly impressed with their sustainable approach to providing medical aid. PINCC’s entire model relies on training nurses, clinical officers and physicians in underserved clinics the necessary components for establishing their own cervical cancer screening programs.  To date PINCC has trained over 400 providers at 27 different health centers!  The exponential impact of this work is so much greater than just the 15,000 women who have been screened during PINCC training trips.  Thousands more women have been screened and treated since PINCC ended their involvement with the clinic sites.

Part of the success of PINCC comes from the huge amount of care taken in selecting project sites ahead of time.  Before PINCC ever agrees to visit a community, they require a signed contract from the hosting hospital or clinic confirming their commitment to establishing a cervical cancer screening program for their patients.  PINCC will then provide between 3-4 site visits over a 1-2 year period as well as remote support between visits as needed.  PINCC will also provide donated equipment to help the programs get up and running, but they also make it clear that local health providers will have to determine their own way to fund the screening program in the long run (be it through governmental support, charging small fees for services, acquiring donations, etc). PINCC provides the necessary training and certification for providers and also helps link providers with their in-country medical resources for more challenging cases that may arise.  Very importantly, PINCC makes sure not to duplicate services by only visiting communities where there are not cervical cancer screening programs already in place, and gets permission from the national Ministry of Health to make sure they support PINCC’s work in the proposed communities.

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PINCC Trainees in Muhoroni, Kenya with examination headlamps after completion of first week of training.

As a volunteer, the experience of working with PINCC is incredibly rewarding. One week is spent at each clinic or hospital site with a focus on training providers in the skills needed to perform screening exams for cervical cancer. During our visits to Kenya and Nicaragua, we saw 100-200 women each week and supervised local nurses or physicians as they performed exams.  Any of the women who had abnormal exams needing treatment were treated that day and each site had several providers who were learning to perform the simple and low-cost cryotherapy procedure with the goal of certifying them on future visits.

It was rewarding to see a large number of women receiving cervical cancer screening often for the first time in their lives.  During our week in Kenya we treated over 25 women with pre-cancerous lesions and during our two weeks in Nicaragua we treated 35 women, essentially preventing each of them from developing cancer in the near future.  We also sadly saw 5 women in Kenya who likely already had advanced cervical cancer.  There may not be much to do to save their lives though they were referred on to the national hospital system for possible treatment.  In my entire 9 year medical career in the U.S. I have only cared for 2 women with cervical cancer.  Thus, I also learned from seeing these more advanced cases and the importance of the training we were providing became all the more apparent.

I cringe whenever I hear colleagues talk about volunteer stints in other countries that are clearly not providing sustainable care.  I feel that more of our volunteer aid should be focusing on improving the existing systems of care in other countries rather than swooping in and providing care that will not be sustained when we leave.  Programs that are designed to teach new skills for local providers, increase access for patients to health services (funding clinics, etc. so long as those clinics can be staffed by local providers) or provide educational and outreach services for patients (e.g. community health worker programs) will ultimately be the most impactful in the long run.  As medical volunteers we have an obligation to make sure we are truly providing meaningful help and not actually undermining the health systems of the countries we are intending to help.  I urge anyone considering a medical trip of their own to look closely at the model of care that the organization follows and ask questions if it isn’t clear how they integrate with local health systems and ensure the long term sustainability of their work.  There are plenty of good organizations out there like PINCC who need our help, but it is important to choose wisely if you want to truly make a difference.

For More Information about PINCC, visit www.pincc.org

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PINCC Volunteer Providers during week in Kukra Hill, Nicaragua Nov 2014.

The Effect of Toilets on Education

Did you know that one of the main barriers to girls getting an education starts in the bathroom?

You read that right. Not a lot of people want to talk about it, but in much of the developing world, one of the top barriers to girls’ education is the lack of safe and separate latrines for girls and boys. In fact, in many areas it’s the number one cause of school absenteeism, ahead of malaria and other diseases. In the United States, being able to find a safe, private bathroom is something that most of us take for granted. But only 45% of schools in the least developed and low-income countries have adequate sanitation facilities.

How does a safe, private toilet influence girls’ education, you ask? Well, first it’s important to note that access to adequate sanitation facilities can influence the education of all children in the developing world. These facilities lead to improved sanitation and hygiene, which in turn, can reduce the number of water-born illnesses and diarrheal episodes that cause  – among other devastating outcomes – school absenteeism. But adolescent girls are at greatest risk for being affected!

When a girl reaches puberty, access to a safe, private toilet can make a crucial difference in whether or not she continues her education. Girls need clean water to wash themselves or their menstrual cloths and a place to dispose of their menstrual pads if they are using them. If girls don’t have access to these facilities at school, they will often stay at home during their monthly periods. In fact, lack of safe, private toilets can cause girls to miss up to 20% of the school year. As one might imagine, irregular attendance can lead to lower grades and may, eventually, lead to dropping out of school altogether.

Also, believe it or not- gender segregated toilets that are located in convenient, safe locations at school can protect girls from violence and assault! Women and girls are often vulnerable to harassment or violence when they have to use shared toilets or are forced to go to the bathroom outside. In one survey of schoolgirls in South Africa, for example, more than 30% reported having been raped at school; often these incidences occurred in school toilets that were either shared or in an unsafe, isolated locations. Such violence is a major deterrent to school attendance, not to mention a girl’s self-esteem and desire to learn.

Finally, when girls don’t have access to a toilet at all, they’re forced to go outside. To retain some sense of privacy (and dignity), many girls will choose to ‘hold it’ or limit their consumption of food and drink to delay the need to relieve themselves. Not only can these actions increase the chance of urinary tract infections, but it also means that girls aren’t eating and drinking as they should, which can lead to dehydration and malnourishment.

In sum, there are already many reasons that put girls in much of the developing world at high risk for either dropping out of school or not going in the first place. But when schools have appropriate sanitation facilities, one of those obstacles is eliminated, and one more girl is empowered to make a difference!

Sources:

“This is the work that sticks”: Stories from Ecuador

During July and August of 2014, one of Minga’s Board members, Karin Friederic (who is also an Assistant Professor of Anthropology at Wake Forest University), traveled to Minga’s project site in Ecuador with two of her students, Ty Kraniak and Bennett Heine. While Dr. Friederic conducted pilot research for her current project and intervention on family relations and intimate partner violence, Ty investigated the effects of the SaludCom project and Bennett lent his support by improving health center facilities, painting the community library, and developing health education materials. Together they participated in medical brigades with health center staff, took jungle treks, swam in beautiful waterfalls at the Bilsa Biological Station, and they learned survivalist cooking techniques, like making rice in bamboo stalks and plantain patties over open fires. Above all, they partnered with local friends and colleagues to improve community health and healthcare through plenty of hard work and laughter.

Here’s one of Karin’s stories from the field:

The generator kept going out. The lights flickered and the machinery whirred. My student, Ty, stepped in with an array of headlamps and flashlights to help the dentist, Thamar, as she continued to clean teeth and treat cavities with her manual tools. She could still see, thankfully, but with two more patients waiting, this now meant at least another hour of work, not twenty minutes. We couldn’t send the patients home—they lived an hour away and had waited all day to be seen. While important, these rural medical brigades (when health center staff travel to a remote community for 2-3 days to provide medical care and health education) were never quite enough. As workers in global health and development already know, administering health care in rural Ecuador is different than health care in the United States. For one, in the U.S. we can depend on a certain level of basic infrastructure (i.e. stable electricity, newer equipment, paved roads). However, in many parts of the world, people are meeting these challenges by prioritizing particular kinds of infrastructure and technology and adapting them to better serve diverse needs and contexts across the globe.

To this end, in 2010 the Minga Foundation partnered with NOKIA to understand how mobile cell phones could be used to improve health communication and responsiveness to local illnesses and emergencies. For example, rather than installing landline telephones and electricity lines, one community in rural Ecuador utilizes cell phones and solar panels for communication and electricity. However, despite widespread success, every project has its hiccups—a truth that, at the very least, always keeps us on our toes. There aren’t enough cell phone towers to provide consistent coverage to these rural areas, and despite early promises from cell phone operators in Ecuador, they lost interest in the project. So, while our health promoters and health committee members benefitted from having quality cell phones, many still had to walk 30 minutes to the top of a ridge or a particular tree to get cell signal. As a medical anthropologist who helps develop health programming in rural Ecuadorian communities, I am consistently trying to take advantage of technology’s benefits (often touted as the simple answer to under-development), while simultaneously developing flexible and adaptive contingency plans; as we have seen time-and-time again in development projects worldwide and in the United States, tech fixes are never enough.

Thus, as part of the SaludCom Project in Ecuador (2010-2014), we’ve been integrating technology with common-sense and culturally appropriate approaches to communication. We’ve given out cell phones and installed booster antennas, but we’re also using additional less-sexy platforms: printed flyers and face-to-face communication. In this region, people have varying access to technology and they live in remote locations (up to ten hours away from the health center); therefore, it is crucial that people receive messages about health center hours, availability of doctors, medical emergencies, health related meetings, and health promotion activities. NOKIA stepped in wanting to provide a silver bullet that would allow us to skip paper and face-to-face interaction. While that approach may have been more efficient in theory, experience on the ground called for complementary strategies to be effective. Our friends in Ecuador demanded that, and guided us to recognize that. Just as Thamar and Ty adapted to electricity shortages by using alternative tools on hand, Minga has been working in close partnership with community members and continually retooling our strategies to make sure that what we do, we do well, even if it takes us a few extra steps. I repeatedly tell my students that the ideas informing the work of global health and development should never emerge “fully cooked” in board room meetings, annual retreats, or even classrooms. Implementing ideas in deep partnership with communities and in radically distinct contexts can be humbling, frustrating, and slow, but after fourteen years of experience, this is the work that sticks. Please share ideas and experiences if you’d like and, as always, I invite you to Minga with Us.

Welcome to Our Blog!

Since this is our first blogpost, an introduction is in order. The Minga Foundation is a nonprofit organization with current projects in Ecuador, Malawi, and Uganda. Although Minga came into existence in 2010, its organizational predecessor Foundation Human Nature USA was founded in 2003. Many of us have been working together for over 10 years, and this is fitting. Why? Because Minga is about more than any of our individual projects; it’s about a set of ideals, friendships, and experiences that span all of our work and all of our time together.

For all of us Minga is about making idealism a way of life. Beyond implementing concrete projects in our partner communities, we also generate ideas of what a better world might look like, and concrete strategies to make these ideas real. How to achieve long-term sustainability in our projects? How to partner as equals with the communities in which we work? How to promote a culture of progressive activism rather than reactive ‘slacktivism’? How to create the conditions in which international aid is no longer necessary, i.e. how to put ourselves out of business? We wrestle with these questions in our Board meetings, in the classrooms where we teach, in the communities where we live, and now on this blog. Stay tuned.

That said, our idealism and the purpose of this blog goes beyond intellectual debates on international aid and economic development. Minga itself is a Quichua term which means ‘collective action towards a common goal’; a process by which individuals come together and invest their individual time and energy towards a shared goal or resource. Community participation and collective action are at the core of all of our individual projects. They are also at the core of who we are as a team and an organization.

We truly are a unique group with a unique model. We’ve grown over the past 11 years as an all volunteer board without physical office space or any of the overhead costs incurred by most non-profits. This is only possible because each of us as individuals is willing to give freely of our time and energy. This generosity applies also to our families, as well. Our parents, siblings, aunts, uncles, and cousins have all at some point made donations, organized publicity campaigns, and hosted annual retreats. They’ve served as accountants, consultants, fundraisers, and cheerleaders, even when Minga work and responsibilities made our lives more complicated. Our board members and their extended families constitute a living, breathing example of individuals devoting time and energy to a larger, shared cause.

You might ask, what is that cause? What is the shared resource generated by all of these individual efforts? The first and most obvious answer is the satisfaction of improving people’s daily lives. Eliminating malaria in El Paramo region of Ecuador; providing access to clean water in Kayunga County, Uganda; improving education outcomes in Kabadula, Malawi. These are results which all of us are proud of and which in and of themselves merit the above-described investments of time and energy.

However, the truth is that all of us get more from Minga than the satisfaction of doing good work. We’ve been with each other through the thick and thin; through moves and job changes, through personal accomplishments and personal crises. Laughter and smiles can be a scarce commodity in life, but every year we leave our organizational retreat with side pains from late night games of Charades and Balderdash. We are always there for each other, and the friendships and commitments we’ve developed go well beyond our work in international development.

There is nothing more idealistic than creating lasting friendships from a shared commitment to making the world a better place. So, you ask, what do we get from our investments of time and energy? Perhaps most importantly, we get each other; and for that reason this blog will also be about us. It will be about our jobs, our pass-times, our cities, and our pets. It will be about the people who make Minga possible. Check in with us to learn about our projects and our ideas, but also about our team and our experiences.

We are Minga. Minga is family. Come Minga with us!

-Dan Kselman, President, The Minga Foundation