Today is a BFD

Sorry for the 3 weeks delay in posting.  Lots has happened -- India's been a great experience so far, and Duke took action on an investment resolution proposed by students on "conflict-minerals" -- can trace the origins of my thoughts on that from a blog post on this site about a year ago! 

But, there's something pretty large about to happen in a few hours.  The Supreme Court is going to announce ruling on the constitutionality of the Affordable Care Act -- and no one knows what's going to happen.  Everyone's in suspense.  You've probably heard the buzz from everyone and everywhere -- this is unprecedented, this is historic, this is crazy.  It is. 

Today is one of those days that will create its own little panel in US history books 40 years from now, that bored 7th graders will reluctantly flip through, stopping to stare at pictures of that pearly white marble building that will decide the future of the individual mandate (and a lot more) today. 

I have no new thoughts to contribute that haven't been written ad nauseum already.  This is a subjective decision.  Whether or not you like broccoli, you can understand the rationale of both sides on this one -- and you probably have nightmares about the word "inactivity." 

Here's one student hoping for the best, praying that a pretty moderate piece of legislation that serves as our only real progress in reforming healthcare since the advent of Medicare can survive this challenge.  But, if not, it's not as if Anthony Kennedy destroyed the nation all of a sudden -- it's further confirmation that it's literally all on our generation to step up and find a way to fix US healthcare 20 years from now. 

Here we go.  Buckle up, folks.  This is going to be interesting. 

Final Thoughts from Juba: Ayn Rand and The Chemistry of Hope

I started this post sitting in Juba International Airport, the same place where two weeks ago, I showed up as some random Indian kid trying innocently (but unsuccessfully) to blend in this foreign land (and also trying to collect the object formerly known as my suitcase).  Now, after being whisked around the world over the past few days to the familiar house of my relatives in India, I'm still digesting all the life -- the conversations, trips, experiences, everything -- I've felt in the past fortnight.  But, as weird as it may sound, the only thought that remains constant during my stream-of-conscious reflections is not an image or snippet of a conversation I've experienced directly, but rather a quote from a book my friend Sarah recommended that I picked up during this trip -- none other than Atlas Shrugged.  Here's the quote:

Nobody can tell what the course of a country's future may be.  It is not a matter of calculable trends, but a chaos subject to the rule of the moment, in which anything is possible.

Not the most remarkable two sentences ever written, but a passage that stuck with me nonetheless.  As I tried to wrap my head around Ayn Rand's thought during this past week, though, I found a shred of myself defiantly resisting to accept it.  I mean, most of it made sense -- that yes, no one can define the trajectory of a nation, and that yes, anything is possible.  But, is the chaos she speaks of really that, well, chaotic?

As it turns out, we've spent centuries trying to discover order in a world composed of a series of random (and seemingly meaningless) interactions of complex entities with each other.  But, instead of thinking about the macro-level factors that define something like a country, we've focused our efforts on understanding the behavior of the most micro-level objects that define our lives.  Sound familiar?  It should.  We've simply called this process chemistry.  The entire discipline is centered upon a fundamental idea:  that with enough time, we can actually observe the "chaos" of billions of atoms colliding with each other, come to understand the inherent order subtly guiding the "chaos" we see, and then harness the "chaos" to produce a meaningful result.  

It's not always simple.  When combining a bunch of volatile reactants in a pot, no chemist knows precisely every interaction at any given point (just ask any Orgo kid about their percent error in lab) -- like Rand said, anything is possible.  Things could be fine and dandy.  Or, as my high school chemistry teacher Mr. Bibeau liked to show us, crazy shit could happen and things could blow up.  But, all of this comes with a crucial caveat the Rand seems to forget:  not every outcome is likely.  

After throwing a bunch of random reactants in a pot and staring at it for a while, you notice something interesting:  the system reaches equilibrium, meaning a certain reaction comes to dominate all the other possible interactions that could have taken place, and as a result, a certain outcome is produced that is ultimately dictated by given conditions.   That's the key part:  this newfound equilibrium is not just dependent on what you throw in the pot, but the environment of the pot itself -- like the temperature, or the presence of a catalyst.  If these things change, then we have ourselves a ballgame -- we might shift the equilibrium, and produce more/less of the product......or, we might even create a situation where a completely different reaction starts to dominate, and produces a brand-new outcome from the same set of reactants.

If this concept holds true for the building blocks of life, then why couldn't it hold for the institutions that guide it?  Just think about the larger-level, objective factors that guide the path of a country -- its history, its economic stability, its resources -- as the "reactants" of some equation.  Think about the eventual outcomes -- peace, war, prosperity, collapse -- as the "product."  Ayn Rand tells us there's a million different ways all those reactants could randomly interact, so there's no way to predict the product.  But, aren't we forgetting something?  What about those external conditions - the temperature, the catalysts - that define our equilibrium?  Ah, the analog of these, my friends -- the external environment, the "temperature" of a population, the presence of "catalysts" for change -- is simply what Rand refers to as "the rule of the moment." 

We've seen it happen before.  This will undoubtedly come as a surprise to all of you, but I was a pretty nerdy kid in high school -- channeling my affection towards my US history textbook in order to cope with my lack of luck with the ladies (jk....sorta), spending time in 5th period daydreaming of what it must've felt like to live in Philadelphia, the hub of the world's newest capital less than one year after the signing of the Declaration of Independence.  This must've been an awesome and ridiculously scary moment -- no one could have really known how this "chemical reaction" called a revolution would really work out.  The challenges were serious, the probability of success dim.  But, for those who valued thought, who valued action, who valued freedom -- no matter how rich or poor -- they knew this was their opportunity to define the rule of the moment.  You know the rest.  With a burning sense of urgency and hope, Americans joined together to raise the temperature for freedom and catalyze a revolution in the name of justice and equality for all.

That emotion used to be abstract, confined to the drab pages of a textbook.  Now, after just a taste of life in Juba, I think I understand.  You see, you can't let the dirt roads fool you -- they're just modern-day cobblestones, defining the humble character of this historic city.  You can't let the collections of lawn-chairs scattered near roadside stands mislead you -- they're the modern-day taverns and coffee shops, where the seeds of passion, idealism, and dissent are planted and cultivated day-by-day.  Don't let your eyes trick you -- Juba is the new Philadelphia.  It's the world's newest beacon of hope, minted as a sovereign capital just 11 months ago.   And, folks here know it, too.  Even though the days may pass by slowly on this tropical paradise on the Nile, there is a palpable undercurrent of energy, of optimism, of hope.

 Indeed, the challenges are enormous -- and at times, the emotion and optimism may be naive.  But, there are those who have their hope grounded in the clarity of reality -- and I can prove it to you, because I've seen it manifest itself in all the people we've met over the past two weeks.

You can see it on the face of Aduei Riak, a brilliant economic and legal scholar who trained in the States after escaping insecurity years ago -- and then, when faced with the opportunity to choose any job she wanted -- returned home to commit herself to public service as one of the only women officials in the Ministry of Defense.  She not only dreams of a better South Sudan, but has the savvy to realize her vision.

You can hear it in the hearty laughs of Chol Ajak, and his friends William and Malek, all members of the Sudanese diaspora who gave up the comforts of their lives (and families) in North America to leverage their talents in business in service of a bigger vision -- to create a South Sudan where anyone can follow the entrepreneurial "American" dream.

You can feel in the words of Mabior Garang and Jok Madut Jok -- one the son of the country's late national hero and director of a trendsetting international school, the other a prominent scholar working to unify the nation as a minister of culture -- as they speak with radical fervor of their shared vision of a free and equitable South Sudan.  Their means to this end may be different -- one dedicating his efforts to education, the other to identity -- but the end is all the same.

It's a hope and resolve that, in many cases, draws on larger-than-life convictions.  You'll realize it with a simple conversation with Dennis, a lifelong Sudanese resident and security officer at our compound, or Abei, a 3rd-year medical student serving as a clinical officer at a humanitarian relief camp.  In their free time, you'll find them reciting Catholic hymns or flipping through tattered pages of the Bible, gaining the courage confront life's challenges -- such as the discontinuation of nearly every medical school in the country -- with everlasting faith.

It's also a hope and resolve that, in many cases, has been long awaited.  You can tell from one glance into the eyes of hundreds of South Sudanese returnees from Khartoum and Kosti, who have somehow found a way sustain a bubbling euphoria amidst their sudden deportation into an unfamiliar land, relegated to conditions of transient squalor.

You can read hope in the actions of the foreign supporting cast, recognizing their role in empowering these individuals to help take ownership of their new land.  They are strong believers in incremental change, knowing that the smallest of their actions will collectively sum to support the largest of transformations in a country that desperately needs it.  You see in the ambitions of grad student Sheldon Wordwell, complementing his research in development practice by providing any assistance he can to game-changers on the ground -- whether that's coordinating the delivery of a tractor-trailer full of medical supplies to a rural clinic, or partnering with a local school to introduce an exchange program to break down barriers between "average" and "elite" in this new society.  You see it in the determination of Sean Casey, Adam Levine, Pranav Shetty, and others of the International Medical Corps -- using their skills in emergency medicine to literally "stop the bleeding" of this country, paving the way for others to come in and implement long-term solutions.  You see in the glint of eyes of international journalists - from Reuters to Al-Jazeera -- searching for a way to shine light o the crises of today, rooting desperately for the home team, and embracing the burden of knowledge that their perspective may dictate the response from the international community.

Sheldon and Mabior Garang

This is definitely not a random sample.  And, it doesn't have to be.   Many folks in Juba may be ambivalent about the trajectory of their country -- and for good reason, as their present suffering is not much different than before.  And, while there are surely more individuals out there eager to shape history, it doesn't even matter if there aren't; my experience meeting these folks has demonstrated that hope is not an empty abstraction we attach to difficult situations to fill some type of emotional void -- rather, hope is a sensation that is the direct product of the recognition of the foundations of progress.

This type of hope is not fleeting.  It does not depart at the first, second, or hundredth sign of adversity.  It's a sensation that occurs when everyone comes to the same realization -- that we actually have all the pieces to make this nation great.  It may be subtle, but its contagious -- and therein lies its value.  Hope has the potential to transform the environment in which the reaction of this nation, or any other, is taking place.  It may start with many or few, but all it needs is a critical mass -- because once that happens, the question of whether a nation will succeed shifts from one of if to one of when.  

No one knows what this country will look like tomorrow, next year, or next century.  The road to prosperity is long, perhaps extending for generations.  But, at least right now, these people are determined to control the chaos of every moment -- on lowering the activation energy for the right reaction to proceed.  They know the odds are often grim, but they're not in the business of abiding by probabilities -- they alter them.  They are unafraid to raise the temperature for progress, calling for the rapid installation of political freedoms.  They are the catalyzers of change, entering public service and setting lofty ambitions just like our Founding Fathers did 200-some years ago.

Time to grab your lab goggles, kids.  There's a revolutionary reaction taking place down in Juba. 

Will this get ugly?

Today marks the last day of my stay in Juba with my friend Stefani.  We've had an amazing day so far (and an amazing trip) -- I'm still processing and digesting, and am working on a summary post that will reflect on all the super-awesome people and experiences we've had! 

For now, though, I wanted to add some more insight into a more technical, solemn subject: the role of oil in the stability of the South Sudanese state.  In the context of that blog, I focused mainly on the long-term obstacles to development a robust health system over the next few years -- including the lack of reliable funding streams from the public sector.  Concept was pretty simple: when you lose oil money, your capacity to provide government-sponsored healthcare diminishes pretty quickly.  This seemed bad, but not devastating -- even without long-term development in the health sector (and others), the country wouldn't be that much different from the status quo, right?

This seemed to be the logic of the leaders of South Sudan -- that, even though pulling the plug on oil would definitely hurt, it's nothing that a country and a people that survived 50 years of conflict couldn't weather through.

It all sounds great!  .....Except for the tiny little fact that it seems mathematically impossible.  In the months after S. Sudan shut off the oil, it was reported that the World Bank notified key leaders that the country was hurtling toward the verge of economic collapse.  Models incorporating the decision to forgo the source of 98% of governmental revenues estimated them approaching total depletion of state fiscal reserves as early as this summer.

I had heard these rumors, and read some articles, but like many folks here, dismissed them to the back of my mind.  It was another problem that could, and would, be addressed sometime soon.  But for now, this country needed the emotional catharsis of finding some way to stick it to the North.  To show them who's boss.  To collectively flip them the bird.   Insert your favorite angry cliche here.

Then, I saw a copy of the leaked World Bank report from March 1st, and actually realized things could get pretty ugly.  The brief is quick to point out that the World Bank has "never seen a situation as dramatic as the one faced by South Sudan", and that collapse of GDP and depreciation of the S. Sudanese currency are rapidly approaching on the horizon. Later lays out a timeline for exhaustion of state reserves based on strength of austerity measures the S. Sudanese government decides to implement:

And, the WB lays out broad social implications of the oil decision, suggesting that the proportion of South Sudanese living in poverty is likely to rise from 51% in 2012 to 83% by 2013.  Enrollment rates in school are projected to drop from 50% in 2012 to 20% in 2013.  And finally, the under-5 child mortality rate is expected to double from 10% of live-births in 2012 to 20% in 2013.  These measures are similar to those of S. Sudan in 2004 -- essentially, the decision to shut-off oil could regress development in some areas to the point where it was before signing of the Comprehensive Peace Agreement in 2005. This report goes onto explain that the decision has alienated some members of the donor community, who are reluctant to fill-in-the-gaps in health, education, etc. for a country that isn't demonstrating the capacity or priority to care for its people. 

Ok, whew.  The situation is sobering.  However,  it's important to acknowledge the fact that I (and economists at the Bank) can talk about these statistics and numbers easily because I never had to live in this country during a time of instability or insecurity caused by tensions with the North.  I can't understand the resilience of this community, nor the ability to bear any burden in the name of their national sovereignty, because we're just observers on the side.   This may be a calculated decision made with knowledge of the hardships to come.  This may be a standoff that is soon to end given the recent talks in Addis with reps from Khartoum.

But either way, at least to me, the numbers don't add up. 


(Edit:  I literally just heard a reporter at the table next to me announce that, as of today, South Sudan is unofficially restarting oil in July.  I'm glad to know this post is much less relevant now.  Oye, South Sudan!)

Homecoming in Juba

Apparently, the new winner of American Idol (Phillip Phillips) was crowned a few nights ago.  I'm generally aloof pretty much everything around in life - including pop culture -- so I had no idea this happened. However, Stefani has been on-top of her stuff, and after becoming a fan of Phillip over time, she happened to start playing his music in our room.   

When his song started playing, I wasn't really listening -- I was expecting something random and poppy to come blaring out from her Mac speakers.  But, when I heard the opening lines of his winning song "Home", something clicked in my head:

Hold on, to me as we go
As we roll down this unfamiliar road
And although this wave is stringing us along
Just know you’re not alone
Cause I’m going to make this place your home

At any other moment, these glossy lyrics wouldn't have caught my attention in the slightest bit.  But, of course, this moment was different. 

Ever since South Sudan gained independence, life became tense for hundreds of thousands of Southerners living in the North.  Didn't matter if they had spent their entire livelihood in Khartoum or surrounding regions -- in a flash, they became foreigners in their own home.  This week, their story took another dramatic turn.  Over the past few days, more than 6,000 South Sudanese living in the North have been airlifted to a makeshift refugee camp outside Juba.    Most of them already spent the past year in settlement camps in cities of Kosti and Khartoum, treated as outcasts from a society that deemed their existence unwanted.

For some, this return marks a jubilant homecoming -- a time to finally return to their culture, their land, and their people after decades of instability.  For others, the move brings only more uncertainty and angst -- a detachment from a world where many have lived for nearly two decades or longer.  Yet, even though each of them may have a unique path that brought them to the dusty streets and sweltering heat of Juba, they all share one thing in common:  this place is now home.

Rows of tents were set up pretty quickly for returnees in Juba

Yesterday, I had the chance to spend a day at the returnee camp assisting the International Medical Corps in providing basic, primary care for those coming back.  Makeshift tents set up in days by the International Organization for Migration (IOM) and USAID served as a hospital, prepared to treat a wide array of incoming cases with a stock of essential medicines, bandages, and a few beds.  Three international physicians and a handful of local doctors were tasked with the challenge of managing health for the thousands of returnees, and had little capacity to treat serious illness -- yet, when you think about it, this physician-patient ratio was probably one of the best (if not the best) in the country.  I was impressed as the two docs I had a chance to really meet -- Adam and Pranav -- came together to supervise the clinic, creating a form of organized chaos that helped address the needs of a constant onslaught of patients.

My job throughout the day was simple: help register folks as they came into the clinic.  The only issue?  Virtually no patients spoke English.  I always knew there would be a day when the errant cries of my Arabic professors  ("Yaa Sanjee, stop sleeping through class!", "Yaa Sanjee, stop staring at the girl in the book!", "Yaa Sanjee, READ!") would come back to haunt me.  Yesterday was that day.

Thankfully, I spent most of my time working with Alice -- a wonderful local staff member who did the lion's share of translating patient information.  But, as the day progressed, I started to registering folks on my own -- and here's where it got fun.  I used my three semesters of Arabic knowledge to extract the patient's name and age....and then I was out.  We then proceeded to stare awkwardly at each other for about 15 seconds, until we acknowledged that no other verbal magic was going to happen.  From there on out, we entered one massive game of charades that become quite comical for everyone else (except for me) involved.  As we tried to figure out their chief medical complaint, I got the hang of (an admittedly pretty crappy) system:

Repeated thumping of chest and rubbing of throat =  cough, a signal to look for respiratory tract infections
Putting my hand on their forehead and yelling "SAHANA!" (hot!!)  =  fever
Pointing to head and making flash-like motions with both hands = headache
Pointing to stomach area and making *whoosh* noises = diarrhea

View of the clinic from the registration desk

Chilling with the registration log!

I'm not even sure if this exercise was useful for the doctors, who would interview patients more thoroughly once they saw them and use their diagnostic prowess to figure out what the deal was.  Eventually, we saw all kinds of cases -- from clinical malaria to moderate trauma to skin diseases/infections to even a suspected case of TB.  But, in any case, it was quite the experience.  No matter the barriers in communication, I relished the chance to get a glimpse into the lives of over 165 people I never would have met before, even if only for a minute or two.

There were all kinds of patients, from 2 month old babies to elderly women who couldn't even recall how old they were.  But, the interactions that struck the deepest were the ones with people my own age.  It was a surreal experience, watching a 20-25 year man or woman enter the tent and take a seat next to me, wearing a hardened expression that cracked at times to reveal a sense of resilient hope.  Many times, they carried 1-2 year old children battling fatigue and cough, seeming to know that finding a way to "cure" an extension of themselves in this camp represented the first of many challenges to overcome in this foreign land called home.

Whenever we see footage of refugee camps on CNN (and in the 30 seconds before we forget about them), we automatically associate them with a sense of despair and depression.  It's a reflexive connotation that seems pretty logical -- living in temporary quarters that lack access to food, sanitation, and personal space is definitely not ideal.  But, at least for now, that's not the vibe permeating the camp in Juba.  There's an undercurrent of energy, of vitality -- there's simply a buzz.  Maybe it's just the novelty of the whole experience; the camp has only been open for a week, after all.  Or maybe, just maybe, it's the fact that no matter how transient or fluid their life seems right now, there's one constant hope guiding their outlook:  they can finally make this place their home.  

A flag stands proudly outside the entrance to the campsite

Healthcare Financing in South Sudan: Drill, Baby, Drill

While browsing through CNN or the NYTimes recently, you might've heard that there's tension brewing on the border between South Sudan and Sudan.  As you probably already know, if conflict does eventually break out, it unfortunately won't be anything new for folks in this region.  Ever since Sudan gained independence from Britain in the '50s, they've enjoyed only 10 years of tenuous peace from civil war.  That's worth repeating.  In the sixty years since gaining sovereignty, there has only been around one decade (between the 70s and 80s) not plagued by regional strife.  Recently, there seems to have been progress, though.  In 2005, the Second Sudanese civil war ended with the signing of the Comprehensive Peace Agreement -- and in 2011, citizens of Southern Sudan overwhelmingly indicated a desire to form their own nation in a historic referendum. 

Recovering from any kind of conflict is tough for any region -- but such prolonged exposure to unrest has had a devastating effect on the development of basic infrastructure here.  Over time, this has impacted the one resource that no country can afford to sacrifice:  health.   

Don't believe me? There's a lot of evidence connecting conflict to deterioration of health systems, and consequently, of health outcomes (thank you, Prof. Stephen Smith!).  But, let's make this concrete.  In 2007, USAID conducted a health system assessment of Southern Sudan.  Here's what they found:

 

In nearly every indicator, South Sudan was under-performing in comparison to peer nations in Sub-Saharan Africa, and even their neighbors to the north in Sudan.  Their maternal mortality rate ranks among the highest in the world.  Quick glances at their immunization coverage and births by skilled attendant (both astonishingly low) indicate that access to even the most basic health services is limited.  I'm no expert, but this doesn't sound great.

Ok, awesome.  Just what you needed to hear.  More depressing statistics about African healthcare.  Hip, hip, hooray.  I get it.  But, before we become too overwhelmed, we gotta realize that these numbers -- while a bit frightening -- point to something important: an opportunity for growth.  They indicate a real problem that, given the proper tools and resources, can actually be addressed.  How do we know this?  Other nations recovering from long histories of conflict (Rwanda, Liberia, etc.) have proven that it is possible to make progress in establishing a functional health system.    

South Sudanese officials seem to have recognized this, as well.  In a National Health Plan released in 2007, they unveiled a lofty vision declaring that basic primary health and emergency services should be provided free-of-charge to all South Sudanese citizens -- and they reiterate this commitment in their 2012 Health Sector Development Plan.  Before you get all skeptical on me, they (at least symbolically) put their money where their mouth was:  in 2006, they budgeted about $13 per capita for health -- more than other post-conflict nations with similar GDP per capita. 

While the Government of South Sudan (GoSS) may be throwing out progressive rhetoric, the real question (as always) comes down to one of implementation.    Out of the many challenges facing the South Sudanese, they've identified two major ones:  recruitment of adequate physical and human resources.  Health infrastructure is poor -- only 26% of health facilities across the nation have been identified as in "good" quality, while 51% are in need of major renovation or replacement.  And, even if you solve the problem of infrastructure, only 10% of people in civil service posts operating these facilities are qualified health workers.  There's roughly 1.5 physicians and 2 nurses available to serve every 100,000 citizens.  Wow.  If any nation wants to take a stab at solving the issue of resources, though, it all comes down to financing -- so let's focus on it for a moment. 

Even in Sub-Saharan Africa, paying for the health of a nation is not cheap.  It's a massive weight to carry even in normal fiscal conditions -- but it's an even heavier burden now, when South Sudan is in full-on austerity mode.  I'm talking like Greece-status austerity mode.  Why?  Well, GoSS has two main sources of revenue for public expenditure:  $$$ from oil, and cash from international donors (Development Assistance for Health). 

First, let's talk petro.  In a nutshell, oil rules across Sudan -- most fields are in the South, and most refineries are in the North.  Previously, the North had agreed to transfer 48% of all refined oil revenues to the South -- which comprised an astonishing 98% of incoming cash for the GoSS.  Essentially, oil was the only way to sustain functioning government.  Well, in the midst of tension on the border, South Sudan shut off the pipeline funneling oil to the north earlier this year -- a hardball move that demonstrated independence from the North.... but also jeopardized the financial stability of both nations.  Negotiations are still underway between the two, and it looks like both nations have to come to some cost-sharing agreement quickly to avert this dangerous game of chicken, but who knows?  So, for the time being, cross off oil as a source of revenue for health systems strengthening.

Now, we're left with money from other countries.  An important source is the Multi-Donor Trust Fund (MDTF-SS).  Essentially, the MDTFs grew out of a joint effort between the UN and World Bank to collect ~$500 million from 14 donor nations to fund pro-poor and pro-peace development efforts across both Northern and Southern Sudan.  Below, lists a breakdown of key sectors the MDTF was earmarked for:

Health accounts for a pretty substantial portion of MDTF funds -- second only to infrastructure.  So far, the donor allocation has helped fund pharma supplies, GoSS vehicles for improved delivery of health services, over a million bednets, and rehab of buildings at Juba Hospital.  Cool, right?  Well, the only problem is that the MDTF has essentially run out -- and, after speaking to Aduei yesterday, it seems like the World Bank and other international donors may be hesitant to give more given the slipshod handling of foreign aid and the country's general finances over recent years.  The 2012 report cites that international donor funding will still exist in coming years, namely from the World Bank and USAID -- but does not cite an estimated figure.  Thus, it's tough to predict what impact DAH will have in coming years.  To make matters even worse, it doesn't help that -- at least in 2007 -- the country didn't have the ability to effectively collect tax revenue, either.

Take-home message:  Financing is a huge question for the future of public-sponsored health care in the area.    To even come close to accomplishing the goals of the Health Sector Development Plan, GoSS would have to increase investment in health to 10% of all public expenditures.  Yet, over the past 5 years, the health budget has shrunk from 7.9% in 2006 to 4.2% in 2011.  Development assistance for health has simultaneously fallen from $214 million in 2009 to $169 million in 2010.  Where's the money going to come from?  That's literally the "million dollar" question....

With this in mind, it should come as no surprise that over 65% of formal medical services are provided by a robust NGO sector in South Sudan.  Though international and domestic civil society have picked up the slack with regards to health, a lack of coordination among these groups and the GoSS has been cited as a major obstruction to progress and efficient use of resources.  In coming days, hope to gain more insight into the benefits and pitfalls of the "vertical" provision of care by NGOs in the area -- will hopefully post some thoughts soon! 

Major Sources:  

Southern Sudan Health System Assessment.  (2007).  United States Agency for International Development (USAID). 

Health Sector Development Plan 2012-2016.  (January 2012).  Ministry of Health, Republic of South Sudan.  Archived at Ministry of Information in Juba.  

 

"This is from America?"

Whew, today was crazy.  Began travels in the early morning Friday, leaving Southwestern Virginia (thanks for getting up at 3 a.m., Mom and Dad!) for D.C.  While at Dulles, ran into a surprise -- after meeting up with Stefani at the gate for our next flight to Addis Ababa, ran into a few other Dukies (Cheyenne and Connor) who were also on our flight.  Those guys were off to Togo to work on developing rural health insurance schemes and build a sustainably-powered computer cluster, respectively -- check out Connor's blog here: http://hipstersintogo.tumblr.com/

The first leg of the trip was fun -- unfortunately, did not get to try any Ethiopian food during the in-flight cuisine (that's what you get for picking the vegetarian meal).   Did get a chance to finish "The Art of Fielding" -- thanks for those of you that recommended I check it out, it was good!  Had a few hours of a lay-over in Addis (my first ever steps on the continent), and then we were off to Juba.  

After touching down, we gathered our luggage and approached the airplane exit only to find..... a wave of heat.  That's literally my first memory.   Can't even really describe the feeling -- of getting all excited to take that the first step into this "mysterious" land, building it up and dramatizing it in your head like a Hollywood script, and then just getting smacked in the face by this heavy wall of 90-degree humid air.  Cleared the sinuses, for sure.  No worries! With senses dazed, walked straight off the tarmac into a one-room building to collect our luggage -- and here's where it got fun.

As we entered, we found ourselves joining a mob that somehow, someway used chaos to create order.   Our entire flight of about 100 folks pushed and pulled their way to their respective destinations -- the line for buying visas, the line for having your bags searched, the line for standing around and waiting idly.  It was sorta surreal watching soldiers clothed in black and grey camo overlook the whole process calmly.  We also found Aduei, an awesome family friend of Stefani's who met us at the airport to help guide us along.   

Then, the bags came.  Within minutes, the crowd that was dispersed throughout the small room was pushed back to form an irregular semi-circle -- and luggage started being dished out from a window outside to the small area of floor space just created.  Stefani quickly found her bag hiding in a little pile near the crowd -- a good sign!  My bag, on the other hand, took a little while longer.  After a few loads came and went, there was still no sign -- and because a large portion of the crowd also remained in a similar quest to find their treasured possessions, chaos ensued.  I (as always) had no idea what I was doing -- so Aduei decided to come to the rescue! She talked to a man working at the airport, and eventually, we were able to match luggage tags with the correct bag -- and I suddenly realized why we couldn't find my bag: I couldn't even recognize it!

Just some normal wear-and-tear.  It's cool, letting the world see your underwear and stuff.  No big deal, right? After taking my bag to get searched, an exchange with a soldier perhaps summed up everything about this moment perfectly:

Soldier:  ".....Hadha min Amreeka?!" (....this is from America?") 
Me:   *blank stare, nodding my head in ambiguous directions* 
Aduei:  ....Yes!
Soldier: ...Vat? How???   
Aduei:  It didn't come like that!
Me:  Yeah!  It didn't come like that!
 ....Several sentences later between Aduei and Soldier in Arabic, which I probably should understand by now but can't....
Soldier:  Hah, okay.  Nice string. *chuckle, chuckle, chuckle*

I mean, at the end of the day, string got the job done.  Some solid string.   Afterwards, we booked it through "customs"  (I flipped my passport open, someone nodded, I just kept walking) and took off for Aduei's car, where we were greeted by her friend -- a graduate student at UF spending time here this summer studying international development.  Thankfully, I didn't lose too much on the way -- my luggage leaked out some toothpaste, some clothes, and a shoe, but it was no big deal!   After driving about 1 km, we arrived at our hotel (nice!) and -- after taking notice of the pictures of the Obama Family and White House in the reception area -- settled into our room.

The facilities are very nice (as evidenced by the fact that I can submit this blog post), and are most definitely on the upper-end of accommodations in this area.  The lodgings seemed geared toward the ex-pat/NGO/UN community (Japan even has a liason office within the compound).  As foreigners, it's strange and a bit uncomfortable having access to all these Western amenities when it's clear that 95% of folks just outside the gated walls don't.  Made the realization resonate even further that we can't aimlessly spend our time in this hotel -- have to be very deliberate in pushing ourselves to reach out, and explore the area as safely and responsibly as we can, for it'll be tempting just to chill.  I'm excited to have arrived.  I'm excited to learn, to experience.  So thankful to all who have helped us along our journey.  We're here.

(Edit:  Hope to post more of my own photos soon.  Government officials and SPLA soldiers apparently aren't the biggest fans of people taking pictures of them, so you have to be pretty sneaky with your camera.  Check this blog's description of Juba International Airport for more info on what today was like!  http://wizzley.com/juba-south-sudan-tourism/) 



 

Confessions from my armchair

So, it's been a long time since we've updated this site -- almost 9 months!  Whew, my bad.  A lot has happened -- some of us have spent time at Duke hosting rallies for health equity, some of us have participated in drawn-out campaigns, and some of us have even spent a semester abroad (looking at you Sagar, Dhrusti, and Pulkit) studying health and development in India and China!  In any case, we're back -- and as a reminder, this site is an open forum where anyone can post ideas, thoughts, reflections, etc!

Okay, with that, I'll start off my inaugural post of 2012 with a confession: I love armchairs.  Er, well, at least I think I subconsciously do.  And no, I'm not just talking about the crazy-shaped stuff you can find at IKEA (though those are cool). 

See, there's one plank of common sense that hit me upside the head over the course of the past 9 months:  it's actually really easy to talk about human rights and social justice.  In fact, it's downright fun.  When fighting for ideals of equity and freedom by spewing out passionate rhetoric and prose, it's exhilarating!  But, it's also comfortable.  Especially for me -- a naive, privileged kid who's grown up on a steady stream of The West Wing re-runs, it should come as no surprise that I eat idealistic language up for breakfast, lunch, and dinner.

Sure, all this stuff sounds pretty obvious (and it is), but this whole concept became really concrete for me over the past year.  After writing a post on this blog last summer about the epidemic of sexual violence occurring in conflict-regions of Sub-Saharan Africa, a few friends and I were compelled to do something.  Anything.  I was familiar with the issue of natural resource exploitation (specifically minerals found in consumer electronics) subsidizing armed groups in these regions because of my friends David and Braveen previously -- and now some of us wanted to take action.  We wanted to advocate, but we realized we might not have the standing to truly make our voices heard in the international debate.  So, in the Fall of 2011, we launched a campaign to lobby our university (Duke) to follow the lead of Stanford and other universities by standing up for responsible supply chains and ethical business practices -- specifically by altering our investment policies with respect to companies sourcing these minerals.

It was my first real introduction to participating in sustained advocacy (not just describing it), even on a micro-scale.  Within months, our coalition found ourselves drafting op-eds, making videos, and pressing our administration for action.  And, we made a lot of progress.  Honestly, it was great.  Throughout the highs and lows, I've never felt more vulnerable or alive - I never stopped learning.

But, in the midst of this experience, a curious thing happened.  I found myself sitting in armchairs a lot.  At first, this was confined to the awkward blue couch in my apartment, where policy requests and editorials were drafted, edited, and trashed because it was more fun than homework.  As the weeks wore on, I later found myself sitting in classrooms and study halls, planning strategy and hosting dialogues with a host of other passionate students.  And finally, as the year ended, I found myself in really comfy armchairs staring blankly at faculty and administrators in fancy boardrooms.  Perhaps that's a measure of success in this stuff -- whether your armchairs get more comfortable over time. 

But, all jokes aside, I realized something about myself:  I was literally an armchair activist.  One of those kids who wanted to "save" the world from the comforts of my own Gothic wonderland.  A student with absolutely no connection to a community on-the-ground leveraging a purely theoretical foundation for justice to make a fuss while sipping bubble tea from my comfy seat.  This isn't necessarily "bad" -- for a neglected issues and marginalized communities, there's gotta be a gain in starting the conversation and shining a light.

So, you may be wondering, what's the problem?  Well, over the course of this campaign, another simple realization dawned upon me:  it's really tough to understand anything from the perspective one has from an armchair.   We can recite talking points from policy briefs, and we can throw out statistics like it's nobody's business -- but, we can't truly comprehend the nuances of injustice. We are compelled with a black-and-white sense of morality to stand up and act, yet the real-time effects of proposed interventions are much more grey.  That's important to realize.  For me, it came with the increased knowledge that the push for more transparent resource supply chains could create more harm than good for those dependent on the industry -- essentially, a manifestation of the "good intentions aren't enough" and "do no harm" mantra for all of development.

For the past few months, ethical questions surrounding the nuance and paternalism of advocacy have weighed on me.  They've gnawed at my core, making me question my values over and over.  The resulting paralysis can't really be addressed because there's only so much knowledge one can derive from an armchair.  When strapped to your chair at, say, a university, the only thing you can do is acknowledge your limitations, try your best to find someone who actually is standing in solidarity (not just preaching about doing so) with your community, and let them inform your humble path forward for responsible action.  At least, that's all I got.  

That's the point of this blog, and the next few months, for me.  These questions aren't specific to me -- they're universal to all kinds of advocacy.  In fact, all of us interested in social action are probably dealing with these in some way, shape, or form.  I'll need your help and your insight -- I have faith these are issues that we can help each other come to terms with.  

Over the next few months, I'll be using the protected time over the summer not to advocate for any cause -- but to sit down, shut up, listen to voices I've never heard before, and gain some skills that could make me more valuable than just a kid with a loud mouth.  On Friday, I'll be traveling to Juba, South Sudan with my good friend Stefani Jones -- a Duke colleague who helped lead the campaign above -- to learn more about life in a country rebuilding and recovering from (and perhaps preparing for) conflict.  We'll be there for about 10 days, and it's my goal to not just learn about challenges in public health -- but to learn about desires for and reception of Western advocacy from everyone, ranging from government officials to regular folks on the street.  From Juba, I'll be traveling to Bangalore, India (with a stop in my parents' hometown of Hyderabad) to work on some health economics research -- a chance to actually understand how science and analytical rigor can be applied to questions of development and health equity.  I'll be posting all kinds of ramblings and musings throughout!

(Edit:  A final confession -- I got tired of sitting in armchairs, so I actually wrote this post from my bed.  Who would've thought?) 

China: The Migrant Condition

            From about 1950 to 1980, the urban population in China actually declined as Mao promoted people to go back the countryside and grow grain. It was a time of cultural revival when the agrarian farmer was romanticized. Rural to urban migration was almost unheard of during this time. When Deng Xiaoping took over, he completely reversed this policy. Through the 80s, the world saw its largest migration. Over 300 million farmers moved from the rural countryside to urban centers.

And China’s cities boomed.

            The economic growth of cities came at a price. These farmers became the migrant workhorses of the cities. Not owning a city hukou (residential permit) that would give them the social welfare benefits of healthcare and education, migrants became a largely marginalized population. The rural migrants became the underpaid, overworked, and routinely abused human capital for China’s cities. As wealth poured into cities, low-end menial jobs were created to support this wealth. Migrants took on the roles of cleaning ladies, physical manual laborers, and bar hostesses serving the well off.

Earning nominal wages, migrants live in cramped quarters and suffer more wear and tear to their bodies than other populations. While the migrants in clothing factories suffer from back problems as they sit in one position for multiple hours a day, the sex workers suffer from physical abuse and mental trauma. I remember Professor Litzinger (our professor in China) saying that almost over 90% of these sex workers arrive from the countryside.

Despite the working conditions, migrants manage to save money and send some back home to aid with the education of the younger household members and the health needs of the older family members. Migrant workers go back to their homes maybe only once or twice a year. During the Chinese New Year, hundreds of millions of migrants travel back home and bring back little gifts and extra money. Sometimes children do not feel a sense of kinship to the parents who see them once a year, which creates an unfortunate family dynamic. Parents pressure their children to study harder so that their children have better lives. Children buckle under the pressure of these authority figures they rarely see and may distance themselves from one of the only sources of guidance they have. These kids may go on to become migrants in other large cities. 

This is the migrant condition.