Researchers as healers or witches?

“A researcher [mtafiti] is an important person because he indeed is the one who discovers everything [anayegundua kila kitu].” – Mzee Thomas Inyassi

Melissa Graboyes describes how research participants in Tanzania see the medical researchers who come to them for samples and information. On the one hand, “East Africans noted the similarity between researchers and doctors: they both gave out medicine and helped the sick recover.” On the other hand…

As healers and witches are understood to rely on the same skills, once researchers were compared with healers, it was not such a stretch to compare them to witches. … Witch doctors often work at night and want blood. … Researchers also worked at night, collecting blood samples by going door to door or collecting night-biting mosquitos by walking around in the bush. For both witches and researchers, blood was valued above all other substances and its use was shrouded in secrecy.

This, from Graboyes’ intriguing book The Experiment Must Continue: Medical Research and Ethics in East Africa, 1940-2014.

Lest you think this is limited only to medical research, consider the following passage from Kremer, Miguel, and Thornton’s randomized evaluation of a girls’ scholarship program in western Kenya:

There is also a tradition of suspicion of outsiders in Teso, and this has at times led to misunderstandings with NGOs there. A government report noted that indigenous religious beliefs, traditional taboos, and witchcraft practices remain stronger in Teso than in Busia (Were, 1986).

Events that occurred during the study period appear to have interacted in an adverse way with these preexisting factors in Teso district. In June 2001 lightning struck and severely damaged a Teso primary school, killing 7 students and injuring 27 others. Although that school was not in the scholarship program, the NGO had been involved with another assistance program there. Some community members associated the lightning strike with the NGO, and this appears to have led some schools to pull out of the girls’ scholarship program. Of 58 Teso sample schools, 5 pulled out immediately following the lightning strike, as did a school located in Busia with a substantial ethnic Teso population. (Moreover, one girl in Teso who won the ICS scholarship in 2001 later refused the scholarship award, reportedly because of negative views toward the NGO.)

Witches or healers?

One take away from this is that researchers need to do more to make sure participants understand what they are participating in.

Cash Transfers and Health: Evidence from Tanzania

My paper, “Cash Transfers and Health: Evidence from Tanzania” (with Holtemeyer & Kosec of IFPRI) has been published in the World Bank Economic Review. The paper is attached. Here is the abstract:

How do cash transfers conditioned on health clinic visits and school attendance impact health-related outcomes? Examining the 2010 randomized introduction of a program in Tanzania, this paper finds nuanced impacts. An initial surge in clinic visits after 1.5 years—due to more visits by those already complying with program health conditions and by non-compliers—disappeared after 2.5 years, largely due to compliers reducing above-minimal visits. The study finds significant increases in take-up of health insurance and the likelihood of seeking treatment when ill. Health improvements were concentrated among children ages 0–5 years rather than the elderly, and took time to materialize; the study finds no improvements after 1.5 years, but 0.76 fewer sick days per month after 2.5 years, suggesting the importance of looking beyond short-term impacts. Reductions in sick days were largest in villages with more baseline health workers per capita, consistent with improvements being sensitive to capacity constraints. These results are robust to adjustments for multiple hypothesis testing.

This is a deep analysis of the health investments and impacts stemming from cash transfers in Tanzania. Here are some other resources from the same experiment:

  1. An open access working paper version of the attached paper is available here (which is substantively the same as the published version), and a summary blog post is here.
  2. A broader analysis of program impacts (beyond health) is available here. A quick summary of those results is available here.
  3. All of the data from the Tanzania community-based conditional cash transfer evaluation are available here.

Thrilling roller coaster with a long wait — a review of Kwei Quartey’s Gold of Our Fathers

Kwei Quartey writes mysteries that give a window into current Ghanaian social issues. Some authors with African ties — Quartey was born in Ghana and grew up between Ghana and the US — cringe at the assumption that they are writing “ethnographic texts dolled up as literary fiction,” as Taiye Selasi put it. Quartey — to the contrary — embraces that role in his crime novels: His first book with detective Darko Dawson of the Ghana Police Service explored polygamy and traditional religion, his second dealt with street kids, his third was set in the oil industry, and — in Dawson’s fourth outing — we come to the gold mining industry in Gold of Our Fathers.

Dawson is a highly capable detective. He’s not corrupt. He’s faithful to his wife. (He almost cheated in the last book, but he just couldn’t do it!) He occasionally smokes pot but he’s trying to kick the habit, with broad success. He’s so capable that at the beginning of this book, he is transferred far from the capital, Accra, to fill in for a deceased officer in Obuasi, a rural gold-mining district in central-southern Ghana. As soon as he arrives a Chinese immigrant miner is found murdered. Dawson is on the job!

My favorite Darko Dawson novel is the second, Children of the Street. This one, by contrast, felt like two novels in the one. The second half is captivating. The first half is paced very slowly (it took me weeks to work my way through) and has far too much language that sounds like “teaching Westerners about Ghana,” as in this exchange:

“How far, boss?” the sergeant asked, slang for “How goes it.”

or this one

Dawson: “I’m broke—can you mobile me a little cash?” 

Dawson’s wife Christine: “Okay—I’ll send what I can by MTN Money.”

Presumably Dawson knows how he and his wife send money and she wouldn’t clarify. There are many other examples. 

I’ve never been to Ghana, and maybe this won’t bother you if you haven’t either, but I prefer the unapologetically immersive style that lets readers catch up on local culture rather than bringing them along by the hand.

If you haven’t read Darko Dawson, start with the first or second book. This book is a great ride if you don’t mind waiting a while to get to it.

How development economists think about development vs how other economists think about development?

In a recent EconTalk episode, Russ Roberts interviews Chris Blattman about his experiment with Stefan Dercon on sweatshops in Ethiopia. 

This exchange amused me.

BLATTMAN: Getting a bad shock when you’re poor means–

ROBERTS: Death.

BLATTMAN: –can mean really terrible things. For these guys, not death. If you have a Grade 8 education in Ethiopia and you have a family that can support you, they’re outside option in the end is living at home and not having anything to do and not being able to contribute to the family, not having any spending money, and maybe having a harder time finding a husband or a wife. Maybe also bad things happen in the household. Maybe you’re contributing to your younger brother going to private school. But these people are not on the margins of death. This isn’t who sweatshops are hiring, at least in this case.

This is NOT to critique the great work that Russ Roberts does on the EconTalk podcast.

But it’s a reminder that many choices in developing countries are not about life or death, but that doesn’t mean they don’t have major implications for human well-being.

Chris Blattman on the incubation of ideas until opportunity strikes

Is a factory job better than a cash grant and some training? Chris Blattman and Stefan Dercon have a recent study in Ethiopia where they test these two options with a randomized-controlled trial. Back in December, Chris Blattman discussed with study with Russ Roberts on the EconTalk podcast.

In one interesting bit, Blattman highlights how holding onto an idea and repeatedly seeking an opportunity to implement it can ultimately bear fruit. I transcribed it (abridging a little for readability).

Since you have 300 people lining up for these jobs, instead of taking the first 50 in line who are qualified for the job and hiring them, why not see if we can find a factory owner who will find 150 who are qualified and instead of taking the first 50, we’ll flip a coin and we’ll take 50 out of those 150 qualified applicants as random and we’ll follow them over time and we’ll look at what happens to their incomes and their health and their career trajectories.

I had this idea as a graduate student 10 or 12 years ago, and I always thought, “Every time I meet a factory owner I’m going to feel him out. And I did. Once in a while I’d be on a plane to Uganda to work on one of my projects, usually related to poverty or conflict, and maybe I’d sit by a factory owner, and I’d say here’s this idea that I have, and they’d usually look at me kind of funny. They wouldn’t leap at the possibility. I was just this person they met on a plane, and I was a graduate student. I probably didn’t approach it well, and so it never really materialized.

So I was at a conference in London and there was an Ethiopian businessman who was sort of a real estate mogul. He was giving a talk to a group of development economics at the International Growth Centre, and I approached him afterwards and said, “That was terrific,” and I really enjoyed talking to him and we kept chatting and I said, “I had this idea. I think that your firms not only help achieve growth, but I think they might actually be tools of poverty alleviation. Here’s an easy way to answer that question.” And he said, “That sounds great. Let’s do it.” And so literally five or six weeks later we were on the ground in Ethiopia doing the first randomization.

I recommend the whole conversation.

Getting true voluntary consent for your field experiment may be harder than you think

Kim Dionne recently interviewed Melissa Graboyes on the excellent new Ufahamu Africa podcast. Graboyes wrote a history – The Experiment Must Continue: Medical Research and Ethics in East Africa, 1940-2014. I’m reading the book, and Graboyes provides a rich picture, filled with first-person reports from East African participants in research.

Dionne asked Graboyes for key takeaways. Here’s one on consent, which very much applies to social science research.

People regularly mistake the idea that they are participating in an experiment and it’s designed to benefit them personally, rather than the experiment is designed to generate data that can be used to answer important questions and hopefully get us closer to solving some important problems. This disconnect is really profound and it jeopardizes consent.

The basic components of consent laid in the Nuremburg code, laid out in European guidelines, laid out in U.S. national law, is that consent has to be informed, it has to have understanding, and it has to be voluntary. So we can inform people by giving them a consent form translated into Swahili. We can inform them by reading that consent form in Swahili. But if they don’t understand what we’re saying and can’t accurately describe back the kind of experiment they’re participating in with the commensurate risks and benefits that go with it, that’s not really voluntary consent, and it jeopardizes the idea that they are autonomously choosing to participate. I think that there’s a lot of research going on that is stumbling at that step, that we’re formally checking all the boxes we need to, but that we’re not adhering to the real meaning of what that rule is supposed to be about. [I’ve edited very slightly for readability.]

The interview has much more, and the podcast overall is a delight. I recommend it and Graboyes’ book.