End User Complaint

The historian Randall Packard gave an interesting talk at Swarthmore last week about the history of malaria eradication. Like many historians, he ends up with a skeptical view of contemporary projects and plans. As he sees it, current attempts to eradicate malaria at the present time are making some of the same strategic mistakes that a post-1945 global campaign to eradicate malaria made. Packard wasn’t arguing that there should be no major global effort against malaria, but instead contended that what we should be aiming towards is a zero mortality campaign focused on pregnant women, infants and children.

I liked the talk and agreed with the argument. I got a bit fixated on one point, far more fixated than Packard does: the contrast between the local context of bed net usage and the technocratic, distant language used about bed net usage in top-level malaria control discourse like the Global Malaria Action Plan. That plan notes very briefly that there are challenges with “end-user compliance”, but not to worry: there’s a place in the plan for coordinated use of communication and behavior change methodologies.

Some of the arguments going back and forth between Jeffrey Sachs and Dambisa Moyo about bed nets are screwed up, partly because Moyo takes a lot of the current critique of development aid from Easterly, Calderisi and other authors and takes away a lot of the complexity and texture of that work. Moyo is convinced that the problem with giving bed nets away is that you put African bed net producers out of business, which really misses the point. I also think the “give bed nets away or sell them” argument isn’t a meaningful or helpful argument about bed net usage in Africa or elsewhere, it’s an argument about an orthodoxy in economics.

Sachs, on the other hand, is pretty much stuck in the same place that the GMAP is when it comes to figuring out why people don’t use bed nets: his perspective is too removed, too far from the actual situations of people who are or are not using bed nets. He knows they should do it, and if they aren’t doing what they should do, then just do some education or something.

Language like “end user compliance” wards off the lived reality of human life like a garlic wards off a vampire. Big plans and sweeping frameworks subcontract out the problem of the local and particular to some yet-to-be-named partner organization who will be charged with dealing with end user compliance in a sensitive, community-engaged, bottom-up, gender-attentive, ethnographically nuanced manner. That way, when the news filters up that end user compliance doesn’t meet expectations, you can just imagine that you haven’t met the right partner organizations yet or that the methodology for securing compliance needs some tweaking. You didn’t get enough medical anthropologists. The medical anthropologists weren’t properly integrated into the plan. Something like that.

The big plan never has to trouble itself with understanding the scene of everyday life or meeting the end users as human beings living in particular places. The big plan doesn’t have to bring what a smart medical anthropologist might tell it about why people use or don’t use bed nets into the language or thinking of the big plan. That’s the subcontractor’s problem. But it’s on these questions that big plans of all kinds stand or fall, and they can only be thought and engaged properly in their own terms, not in bloodlessly technocratic language.

You have to be able think at the top level, in the big plan, about local ideas about illness and local ideas about sleep, local arrangements of household space, local furnishings, local material conditions. And understand that these things vary.

The top planners have to understand that in historic terms, it’s perfectly sensible to mistrust development organizations in many parts of the world. Sometimes they have had actively bad ideas that caused damage to local communities and sometimes even when they have had good ideas, they only pursued them for a short while until they got bored or distracted or there was a new fad or a change in political administrations or the money dried up. Then the people who really bought into the good idea were left holding the sack.

The top planners have to get away from data that shows that bed net usage has a huge impact on malaria transmission to understand that sleeping under a bed net can be uncomfortable and annoying. That many adults who’ve had malaria tend to treat the disease the way we treat the flu: annoying, frustrating, a bit scary, but tolerable. It’s not hard to wash your hands and use hand sanitizer regularly, and those cut transmission of the flu. But for a lot of people, the minor hassle of regular hand sanitizing isn’t quite worth whatever percentage fewer times you’d have a cold or flu.

Every public health campaign that starts from the premise that there’s a simple and rational preventive behavior change that people of course should adopt is setting itself up for failure, because it’s not thinking clearly about how most human beings in general inhabit the landscape of habit and convenience and risk-calculation, let alone local cultural framings of those same things. Public health campaigns sort of start by taking educated professional white Americans and their particular cluster of common attitudes and cultural postures as the norm and everything else as uncompliant end usage or uneducated deviance. Among other things, if you want to convince people to better safeguard their own health and the health of other people around them, you’d better back up a bit and find out whether they care much about their own health and the health of other people around them. That’s not a universal, and not caring doesn’t make someone a monster or a sociopath. If I lived in a world that was full of political disorder, economic failure, endemic violence, if planning for the future was a sick joke, I might find it faintly ridiculous when some well-meaning person kept telling me how important it was to sleep under a bed net.

If you’re planning for action, well, this is what action really is all about. Anybody can make a comprehensive ten-point plan that neatly subdivides the messiness of lived experience into dry subheadings while keeping an antiseptic distance from that messiness.

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7 Responses to End User Complaint

  1. Matt Lungerhausen says:

    Wow. That talk sounded really cool. Its also a pretty convincing argument.

    To be less high minded, and more self-absorbed, I think the same rules of action at a distance might apply to the implementation of my department’s assessment plan.

  2. Jed Harris says:

    Of course this perspective was developed extensively by James C. Scott. To me your phrase “the local context of bed net usage and the technocratic, distant language used about bed net usage in top-level malaria control discourse” strongly echos your comment a few posts ago about how “the abstraction of the public interest seems impoverished and cold compared to the vivid individuality of real people and real circumstances.” (in “One Man’s Moose”).

    I pretty strongly agree with Scott and you (and I think Packard, I couldn’t quite figure out his position from your account) about the nature of the problem. Scott is an anarchist so may not feel the state, or state supported NGOs have a positive role. But I take it you and Packard feel it does — as do I. Even Scott probably sees a role for very large scale collective action.

    So let’s take things in that direction. Given these systematic and well documented failings for large organizations, what should be their positive social role? What culture, goals, aspirations, status etc. should we get them to adopt? “Rational plans”, “getting people to follow expert advice” etc. are clearly the wrong answers. But what are the right answers?

    Getting people to reject the current modes of thought because they are flawed usually doesn’t work. Displacing current modes with better ones sometimes does.

  3. Timothy Burke says:

    Agreed. This is where I quite like what I understand Easterly to be arguing in his most recent work: away from “projects which are too big to fail” (like Sachs’ Millennium Villages) and towards lots of little, robust, consciously experimental projects which require little or no continuous staffing and supervision by NGOs but which have to set concrete goals or make concrete predictions about their impact, which are held accountable for what happens as a result of the project.

    Essentially it seems to me that development organizations should look at the way cell phones have disseminated (to great developmental effect) across rural Africa and ask, “So how can we by design do something comparable to that? Small changes that make big differences?”

  4. Timothy Burke says:

    (And, I should note, small changes which thrive off of understanding the real ethnographic and human situations of the people that we aim to help. That’s the other thing about cell phones: their spread makes perfect sense if you know what life in a lot of rural Africa is like.)

  5. Robin Hanson says:

    The essential problem is our using the “far” mental mode, induced by ideal motives applied far in space and time, rather than the more practical “near” mode.

  6. Carl says:

    Well yeah. But I guess I see a symmetrical problem here: the big institutional planners make a mistake by projecting their notions of how people ‘should’ act onto complex local dynamics of which they have very little understanding. Then we look at that and project our notions of how big institutional planners ‘should’ act instead. Hm.

    Why would we think that governments and ngos are any more easily persuadable by straightforward goal-directed rational argumentation than localities x, y and z? Is it just that they need to be better educated?

  7. Jed Harris says:

    This conversation interests me a lot. Unfortunately I’m not sure commenting on four day old blog posts works to continue it, but I guess it is the best medium we have right now. This is a structural problem for us web-oids and our discussions.

    Responding to Timothy’s comment: I certainly agree that moving development efforts “away from ‘projects which are too big to fail’ … and towards lots of little, robust, consciously experimental projects” — this pretty clearly enables more rapid learning and evolution if the projects contribute to the “DNA” of subsequent projects in ways that appropriate reflect their successes and failures.

    I guess I’d claim that sometimes projects do have to be big to work. This issue shouldn’t become a roadblock but an approach that can’t handle it ultimately will need to be changed / augmented, and that presents a danger of sliding back into a “big project” mode…

    Continuing with Timothy’s comment: we should prefer projects “which require little or no continuous staffing and supervision by NGOs but which have to set concrete goals or make concrete predictions about their impact, which are held accountable for what happens as a result of the project.” Actually, I think this is not exactly wrong, but skew to what is actually needed, in a way that will perpetuate some serious problems.

    Projects can be viewed as having two important results: their immediate success or failure on their goals, and their contributions to future projects in terms of understanding “how to get it done” and also sometimes “what to get done.” Focusing on the “concrete goals” has virtues but also makes it hard or impossible to learn important lessons from projects. Even more important, it mis-directs the focus of the larger scale institutions away from the learning process in favor of easily measured outcomes which may not be anywhere near the most important results.

    To sharpen this point, let’s consider a project to distribute mosquito nets which uses the currently most favored “consensus” approach, and clearly fails. The project could be a huge “success” in terms of the future of the overall effort if it turns out it was executed well and failed for reasons more or less intrinsic to the consensus approach.

    A less dramatic and more realistic example is a project that tries the consensus approach but finds they need to modify it significantly to make it work. In the end they are neither particularly successful or unsuccessful, but they do invent / discover / refine some tactics that are helpful, and also identify some that don’t work in their situation. This doesn’t fit the clean popperian falsificationist model, but of course is much closer to how researchers learn from real experiments.

    Results like these, if studied and respected, will motivate and guide improvement of the consensus or replacement with something better. But if the projects are simply evaluated in terms of success in achieving goals, we are throwing away a lot of opportunities to learn from analysis of the fine structure of the results. The “accountability” trope basically tends to imply “failure makes projects losers to be scorned, success makes projects heros to be emulated” which to me bears an uncomfortable resemblance to the “personal responsiblity” meme that seems pretty pernicious but also culturally pervasive.

    Being able to learn effectively on this large institutional scale requires a very rich and well maintained context of reporting, analysis of success and failure, propagation of new perspectives, maintenance of appropriate norms of discussion and epistemic rectitude, etc. That kind of context doesn’t just happen, it needs to be cultivated and sometimes enforced. We have a variety of institutional examples where it is done better or worse. Unfortunately in this kind of example if done worse (as I suspect it usually is in development) it will kill substantial numbers of people and possibly wreck entire economies and regions (as e.g. the post-soviet union economic interventions wrecked that region).

    If I was running the QA department of a large development organization (and probably no such department exists, which is part of the point) I’d try to define my role as monitoring and improving the epistemic culture.

    I’m not sure why the institutional culture of development projects is so much less effective than e.g. the institutional culture of airplane safety. Maybe it is just that the constituents for good development are so much weaker relative to the institutions. But this is what I’d like to fix.

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