Long Live The Public Beach!

Public transportation and public space are two of my abiding passions, and I've been dying to write a post on them for a long time. In my last post, I was going to offer my alternative guide to starting a cause, but discarded it because it sounded too angry:

"Step 1: DON'T meet up with other people like you who are on Facebook. Step 2: DO meet people who don't share your socio-economic background. Step 3: If you think that volunteering will bring you too much discomfort, at least ride a bus!"

If you ignore the venom, the point that I was trying to make is that I think the real joy of giving comes not from writing a cheque or following a cause on Facebook, but from making a difference in peoples' lives. And the first step towards making a difference in peoples' lives is to understand their lives, and riding the bus is the first step towards doing that. Yes, buses can be extremely hot, extremely crowded, and for women dangerous because of all the groping that takes place. I'm certainly not condoning the groping. But buses are also one of the only places in the city where construction laborers, students, housewives and office-goers can sit, stand and travel as equals. Or so I thought.

I was just in Kerala, and found the bus system pretty difficult to navigate because almost all the signs are in Malayalam. I finally figured out where the buses to Kovalam stopped, and was waiting when an AC bus came along. I noticed that, unlike the matter-of-factly labelled "ordinary buses", the signs on the AC bus were in English alone. Inside, there was a high-tech display running instructions on how to behave in the bus, also in English alone. Clearly, there was an expectation that wealthier, English-speaking passengers would take the AC bus, while poorer, Malayalam-speaking passengers would take the ordinary bus. And they were probably right.

There is an environmental argument for AC buses, because they coax car-drivers to take the bus instead. But in the process, they segregate one of the few spaces in the city that was public. This is unfortunately true for most forms of public transportation. In inter-city trains, the better-off passengers are esconsced in the AC cars, where even the intrepid platform vendors fear to tread. In commuter trains there are still first and second classes, despite both being non-AC.

As I was thinking about this I finished Jeb Brugmann's Welcome To The Urban Revolution. There's a lot of material in this book on public space, but I'll just focus on his chapter on the Brazilian city of Curitiba (12). While Curitiba is known for its bus system, the city's mayor convinces Brugmann that the bus system is just one part of a larger strategy to draw people to a range of public spaces, that include open-air shopping plazas, parks and river basins. This got me thinking about whether there are other kinds of public spaces here that I've neglected to see.

In the Indian context, one such public space might be places of worship. Yet while churches and mosques might do a better job at this, in the main Hindu temples you again have a system where the more you pay, the less time you have to spend in line rubbing shoulders with - well, the public.

As I was beginning to lose all hope, I remembered the beach. Notwithstanding recent efforts, Chennai has very few parks, and the beach is one of the only open spaces in the city. And thankfully, these city beaches accomodate middle-class walkers, the ubiquitous vendors, fisher-folk, and a whole host of other characters without too much segregation.

Even attempts to escape these beaches for a more exclusive experience further down the East Coast Road are not entirely successful. The Ideal Beach Resort is a popular destination because tourists and brave Indians can sunbathe in relative privacy. Yet even here, like clockwork every evening, a local herder strides across the beach with his goats, confident that he has the right of way and the hotel staff won't try to stop him.

On our last day in Kovalam we decided to splurge on tea and cake at the five-star Taj resort. The Taj property goes right up to the beach, and occupies a vast expanse. As we walked down its length, we saw only a handful of people - a security guard, a waiter, a couple of guests, and two fishermen. Again, they strolled through the Taj, fish in hand, at ease knowing that at least for now, their claim on the beach as public space, and the source of their livelihoods, is secure. Samanth Subramaniam's Following Fish: Travels Around The Indian Coast is currently waiting on my bookshelf, and I'm eager to think more about this as I read the book.

But, it's quite likely that there are public spaces in which the poor and rich co-exist as equals, that I just haven't thought of. Brugmann's description of Curitiba made me stop to consider vegetable markets and other bazaars in India, and whether these might qualify. If there are public spaces that you know of that could be interesting to reflect on, please add them here.

Give (Or Take) India

I was recently flipping channels, and uncharacteristically stopped at an episode of Tech Toys (August 13th), because they were interviewing Venkat Krishnan, Director of GiveIndia. Venkat is a friend of my cousin and I've met him once or twice, and knowing a little bit about his work, I was intrigued to find out what he was doing on Tech Toys. It turns out Venkat was there to introduce the Joy of Giving Week, conceptualized by GiveIndia. While giving money is of course one option, Venkat emphasized that habitual "givers" tend to increasingly give more of their time, to better understand the causes that they are giving to. To help them, GiveIndia has a strict set of criteria through which they have whittled down over 3,000 NGOs or non-profits to about 200 that are worthy, or credible enough, to give to.

Venkat's interview was spliced with a step-by-step guide to starting your own cause. It went something like this.

"Step 1: Buy your own domain name. Step 2: Create a Facebook page. Step 3: Make sure you keep your Facebook page updated regularly. And if you're going to be travelling, make sure you buy this laptop and the Tata Photon Plus data card to enable you to stay connected to your cause while travelling".

And then we reached the climax, the laptop and data card displayed on the TV screen with the price tag boldly beneath them. The format, and presenter, of this segment were clearly working off the Tech Toys template that they use for all their other episodes.

However, Step 4 provided me with a glimmer of hope because it was, "Make sure your cause doesn't just stay online".

"Aah," I thought, "now's where they're going to talk about what you can do to volunteer, whether it's travelling to rural communities, cleaning up city beaches or whatever".

But no. Step 4 was organizing a meet-up of the fans of your cause on Facebook, and then posting those photos online using...you guessed it - the new camera that's a must-have for starting your cause.

There was an obvious contradiction between this segment and the interview with Venkat, where he emphasized giving. In contrast, for the folks at Tech Toys, any cause begins with buying, for yourself, a new laptop, data card and phone.

However, there was also a less obvious contradiction between the two segments. The "Start A Cause" segment suggested that any cause, if it has an up-to-date, photo rich Facebook page and is marketed right, is worthy of and will receive funding. While NGOs have long been criticized for being publicity-hungry, in India there is now increasing pressure for them to appear "professional". This can lead to a bloated marketing budget, and neglected work on the ground. In contrast, GiveIndia, through its due diligence process, emphasizes that it is credible NGOs that are worth donating to. Another element of credibility for NGOs is a robust impact assessment methodology, which I've been talking about in other posts.

The Mystery of Cambodian Music Videos

On a recent trip to Cambodia I spent a lot of time in buses, travelling from Siem Reap to Phnom Penh, and then from Phnom Penh to Kep and back. And these buses fed us with a constant stream of Cambodian (or Khmer) music videos. In many music videos, the theme was "cool guy has flashbacks of time spent on the farm with village girl, his one true love".

At one level, these videos didn't surprise me at all. In most private "travels" buses in Tamil Nadu, passengers are subjected to movies, and these also contain very similar music videos of lush, fertile fields and romances with village belles in traditional clothing.

And, the Cambodian countryside is beautiful. Relieved to be off the bus, my husband and I rented a motorbike and went exploring down some village roads. Winding past hillocks and across verdant rice fields, we were joined by several other bikes taking guests to a local wedding, that was advertised for miles around by more of the same, blaring, Khmer pop. Looking for a little more peace and quiet, we came across a Buddhist temple. Made new in the traditional style, it stood stiffly at odds with its surroundings. This severity was, however, broken up by a group of schoolgirls who had gathered lotuses on their way home, and were shyly burying their faces in them. Soon after we met a bunch of much less shy, younger kids, playing in the water from a punctured pipe. One of them was too small to stand properly, and he fell in the sand, grubby and bawling, but adorable anyway.

But at another level, the music videos took me completely by surprise, precisely because they were being made and played in Cambodia, not India. Modern research has estimated that approximately half of the people who died under the Khmer Rouge in Cambodia died from starvation and disease. This was as a result of the forced relocation of Phnom Penh residents into the countryside. They were expected to triple Cambodia's rice production, despite not having farmed before, and if they tried to feed themselves on wild berries, this was condemned as "private enterprise". The forced relocations began in 1975, a date that is still within living memory for many people, and even more recently thousands of mass graves have been found all over the countryside. Since the total death toll is most commonly pegged at between 1.4 and 2.2 million, this would mean that 0.7 to 1.1 million people died largely because of forced relocation to villages. Given this bloody history, how is it that Khmer music videos can still portray the village as the site of beauty, innocence and romance?

Perhaps the intended audience for these music videos are those who were already living in villages when the Khmer Rouge came to power (and were treated comparatively better), and who continue to live in villages today. Or perhaps the rural does have a pull on our imaginations, that defies even the harshest realities. But I didn't spend enough time in Cambodia and don't know enough (well, any) Khmer to be able to say this with any certainty. However, in the context of Tamil Nadu I've given this more thought.

Anyone who has compared Hindi and Tamil music videos will notice a marked urban-rural difference between the two. In Hindi music videos, everyone is rich, lives either in Bombay, the U.S. or Europe, and spends all their time in clubs either wearing, or looking at, short skirts. If there's a village scene, it's when the hero returns home for a holiday, and meets the simple village girl of his dreams.

In comparison, there seem to be many more Tamil films where most of the story takes place in the village, where you have both villains as well as romantic heros and heroines. My guess is that this is because Tamil movies still cater largely to the domestic Indian market, whereas Hindi movies have their eye on the diasporic market, which although smaller than the Indian one in terms of numbers, brings in the money.

Why is all this important? Because movies are key to shaping our aspirations, for all of us - but particularly in villages where fewer sources of information are available. I'm not against urbanization or migration per se, but it is worrying that Hindi movies present the West as a place where everyone gets rich immediately, a situation that is not likely to come true for many first-generation migrants. While Tamil films are completely unrealistic in terms of their fight scenes, song-and-dance sequences, and perhaps plot lines, the fact that they neither idolize nor completely ignore rural places could bring us gently down to earth.

Peepli [live]

5 days ago the Hindi movie Peepli [live] was released in theaters across India. Peepli [live] is the story of Natha, a farmer from the village of Peepli, who loses his land because he defaults on a loan. When Natha and his brother approach their local politican for help, they are told facetiously that if one of them commits suicide, perhaps the compensation that the government will give them will be enough to get their land back. Natha and his brother take the politician's words at face value, and Natha is hoodwinked by his brother into agreeing to commit suicide.

When Natha's decision gets out, the local politicans first threaten him. But then, realizing that it is election season and that they have to be seen to be doing something, they gift him a water pump and a color TV. There is a wonderful shot of the interior of Natha's hut, with him, his wife, brother and 3 children hovering around the pump and the TV, because they have neither the money to install the pump nor the electricity to watch the TV.

The Chief Minister of Natha's fictional state of Mukhya Pradesh is a political rival of the Minister of Agriculture in the Central government. To safeguard his reputation, the Minister announces the Natha Card (presumably a credit card for farmers), knowing full well that the Center has no funds for such a program, and that the costs will have to be borne by the States. Ironically, Natha's family themselves are ineligible for the card because to qualify they in turn must have the Below Poverty Line card, which they don't.

Yet the "live" in Peepli [live] is for the role that the media plays in this story. Natha makes headlines not only because it is election season but also because he is, as journalist Nandita oxymoronically describes him, a "live suicide". Natha's story becomes the means by which Nandita attempts to bolster her flagging ratings, with the hook, "Will Natha commit suicide or, won't he?" pulling viewers back to the TV again and again. In the media circus (literally) that ensues, the fundamental issues of Natha's land, and the much larger context of agrarian dispossession in the country, are completely ignored.

Peepli [live] is a farce, but what makes it so poignant is its ability to tell the truth. For anyone who has experienced or observed the Indian political system, Center-State conflicts, populist promises that deliver color TVs but little development, and the maze of bureaucracy that confronts any effort to claim benefits are all too familiar. Similarly, my husband and I often sum up the creed of India's 24-hour news channels as, "It's all happening now". No doubt this is a trend sweeping news channels across the world, but I wonder if they have taken it to the extremes that India has. NDTV, which continues to be a popular channel and, for many Indians was the first alternative they encountered to the government-sponsored Doordarshan, has 4 lines of scrolling and flashing text across its screen.

Although the movie ends on a sober note, I left it with a feeling of optimism. Peepli [live] joins another recent movie, Love, Sex Aur Dhokha, in using one form of visual media (film) to critique another. In Peepli [live] the critique is of course of 24-hour news, while in Love, Sex Aur Dhokha it is of the ubiquity of video in our lives, whether in home videos, Internet porn or camera surveillance.

While Love, Sex Aur Dhokha had at least one song-and-dance sequence, in Peepli [live] there are none of the formulaic elements that are common to Indian films. Yet despite its serious subject and treatment, Peepli [live] is a very well-made, entertaining film. If such a film can fill seats, it has the ability to tell an in-depth, nuanced story - exactly what is missing in our news channels today. And there may be opportunities for these competing visual media to infiltrate each other, as with NDTV airing documentaries on developmental and social issues. Of course, the subtitles on these documentaries are often completely hidden by all those lines of scrolling text.

Villgro Blog: ANDE Impact Report

In an earlier post I had pointed out some weaknesses in the research methodologies of the Ashoka and Beyond Profit surveys of social entrepreneurs. At around the same time that the results of these two surveys were published, ANDE also published its own impact report. ANDE is the Aspen Network of Development Entrepreneurs. How does their report compare to the Ashoka and Beyond Profit surveys?

In brief, the ANDE report is more transparent about how it arrived at its results than the Ashoka and Beyond Profit surveys. However, there is some variability in the completeness and clarity with which the data is presented.

Although ANDE’s report describes itself as an “impact report”, it is really only two sections that are about ANDE’s work. In addition, there is no mention of the methodology used to collect the data in these two sections. Despite the strengths of the report, this is a major weakness.

The two sections that are on ANDE’s work are titled, “ANDE’s Role and the Impact of Our Members”, and “ANDE’s Efforts To Grow The Sector To Scale”. Of these, the latter section consists of straightforward reporting on ANDE’s activities over the year. Therefore I will focus only on the section titled, “ANDE’s Role and the Impact of Our Members”.

In this section, it is Figures 9-14 that I would like to comment on. All figures report results in terms of percentages. In my earlier post I had said that the problem with using percentages alone is that we have no way of knowing if these results are due to chance, because these results were not tested using a test like the chi-square or t-test. However, I realized that I need to explain this further.

Chi-squares or t-tests are needed if you are collecting data from a sample of respondents, and using your results to generalize about the larger population that they (supposedly) represent. Using percentages is not a problem if you have collected data on the entire universe that you are studying. Look at Figure 13 of the ANDE report, for example. The figure is titled, “How ANDE Members Fund SGBs’ Financial Needs”. We are told earlier in the text that ANDE members who invest in SGBs (Small and Growing Businesses) manage 51 funds (23/24). The N=51 at the bottom of Figure 13 tells us that data from all 51 funds is represented in this figure.

Similarly, Figure 11 is also quite clear. It shows how many ANDE member funds have a target return range of 0-5%, 5-20% and above 20%. Here, as in Figure 13, the universe should be 51, as that is the number of funds that ANDE members investing in SGBs manage. However, it is explained that for this figure N=48, as three ANDE member funds did not provide their target IRR range. The only flaw in this figure is its titling. It is titled, “ANDE intermediary target benefit: Percent of ANDE member funds with target IRR range”. This suggests that respondents were asked a yes/no question, such as, “Do you have a target IRR range?” Instead, respondents were probably asked a question like, “What is your target IRR range?” and their responses indicate the spread of ranges. In addition, IRR is not defined in the figure, nor is there a glossary.

Other figures are more ambiguous. There is no N given for Figure 10. Since the title of the figure is, “ANDE intermediary target size: Percent of ANDE member funds with target average investment size”, should we assume that N=51? The title also suggests a yes/no question as with Figure 11. Figures 12 and 14 both say that N=70, and includes both funds and capacity building providers. Yet the term “capacity building providers” is not explained anywhere else in this section.

The text in this section is well-supported by footnotes, and doesn’t leave room for misinterpretation. Where the report says that, “ANDE members have made 2,499 investments in SGBs totaling $830 million (26/27)”, we can see from footnote 15 that this information was collected from all 51 ANDE member funds. Where it says that, “33 ANDE members spent $96.8 million on technical-assistance activities (26/27)”, footnote 17 tells us that data was not available for the remaining ANDE members. And the $1.7 billion in additional funding that ANDE portfolio companies have secured is, as footnote 19 tells us, based on reporting by 21 funds.

It is important to note that, as in some of the above examples, ANDE has most likely underreported their results rather than extrapolate where data is not available. This is to be appreciated. The one exception I found, where the footnote did not explain the text well, was 16. If you read the text and the footnote together, it says, “Among those funds that reported historical investment-size information for these past investments, 96 percent of the total number of investments made were investments under $2 million (26/27)”, excluding one ANDE member fund representing 450 investments that did not report quantity under $2 million. We don’t know what the total number of respondents was (those that reported historical investment-size information), and we also don’t know why one fund was excluded.

Praise Dancing

Because my favorite book has the word August in it, this month makes me stop and take note every year. This year, I think I'll remember August (or the first half of it at least) by two events.

The first event is Aadi. Aadi is the month in the Tamil calendar when I can forget about sleeping. The drumming on my street corner begins at 6 a.m., if not earlier, and goes on till later and later every night. It doesn't help that by August, my pride in my ability to brave the Chennai summer has worn thin. I know that there will be no release from the heat until November, and yet the tempo of the music mounts and mounts, culminating in a frenzy of drumming until the early hours of the morning. It's at about this time that the women start to go into a trance at the temple outside my gate.

I like the exoticism of being able to describe the scene to my friends in the West, but other than that I feel no connection to these women or this form of religion. For my birthday this year I went to the Ramakrishna Math, a temple (if it can be called that) where worship consists of sitting in a hall in silence. I've been brought up in a family that likes to keep rituals at arm's length, and prefers the philosophical side of religion. For me, religion has always been about finding peace, and I've always thought I disliked popular temples like Madurai Meenakshi, Tirupathi and Guruvayur for all the noise and chaos.

The second event of August for me will be the Salsa Congress in Bangalore, if I get my act together and register. I joined salsa class as a skeptic who wanted to believe. I was willing to forget some workshops I had taken many years ago in which I had disappointed myself, and put all my faith in one enthusiastic instructor.

After nine months, I am gradually falling more and more for salsa. Yet I must confess, it is not my first love.

There are some types of dances that I just get, intuitively. Jive, for example. I've never learnt it formally. And of course a good partner is essential. But if my partner lets go, my body naturally comes up with steps that seem to make sense. It's easy for me to enjoy myself.

The most intuitive type of dancing for me, though, is African. African dancing is one of the most difficult forms I have learnt, and I know I have lots of room for improvement. But even when I'm dancing on my own, to any vaguely rhythmic music, my steps unconsciously end up looking kind of African.

Salsa, on the other hand, for me is not intuitive. I know that some day, if I keep at it, the steps will become second nature to me. Nevertheless, it will always be second nature, and the fact remains that it's a learned dance for me.

The other thing I love about African dance is that there's a moment in the music, translated as "the break", where all of the dancers are supposed to lose control, and supposed to not do the steps. The idea is that this is the part of the song where you dance for God, and it's really only God who's in control. In salsa I haven't yet figured out whether it's ok for the woman to lose control or not, but either way, the man is always supposed to be in control. So for all these reasons, I've been trying to track down an African dance teacher who I heard is in Pondicherry, but to no avail.

This evening I've decided to accept defeat, and am escaping Aadi by closing all my doors and windows, and turning on the AC. The drumming is still audible through my walls, but I'm mentally distracting myself by thinking about salsa class tomorrow. As I lose myself in my thoughts, I slowly realize that I am imagining salsa to the beat of the drummers outside. I get up to try it, but after a few awkward steps slip quickly into African dancing.

The next season of So You Think You Can Dance has started, and this week I watched a boy audition whose mother is a drug addict, and for whom dance is his salvation. By the end of his piece his arms were up in supplication, his face was raised to the ceiling, and he was dancing directly to God. The judges referred to it as "praise dancing". It was a phrase I'd never heard before, but it struck me that that was exactly what I was doing, in my room. And that those women going into trance outside my gate might have a thing or two to teach me.

India's Big, Dirty Secret

Between 2001 and 2007, nearly 5% of female births in India did not occur because of pre-natal sex selection. It's tempting to draw attention to the magnitude of this tragedy by saying that it is equivalent to 600,000 girls going "missing" at birth every year. And that this is much higher than the number of people we lose to farmer suicides which, although a very important issue, receives much more media coverage than sex selection.

But I want to be careful here. From a pro-choice perspective, fetuses are not people. Nevertheless, the deliberate targeting of female fetuses is still horrifying.

Why is this happening? To put it crudely, for their parents, daughters are an economic/financial loss, not gain. They are a loss because of the dowries, or "gifts", that the bride's family have to buy for the groom's family at the time of the wedding, and because once married, even if the bride earns, her income goes to her husband's family. Traditionally dowry was only a practice in Hindu families, and in fact in Muslim families, the bride-price was paid by the groom's family to the bride's. However, this might have changed today.

In 2008, the Indian government launched a program that provides Rs.200,000 to the families (preferably mothers) of girl children. They will receive this amount spread out over 18 years, if certain conditions are met, such as making sure the child gets vaccinated, stays in school, and doesn't get married before 18. For 2008-2009, the government had set aside money for approximately 100,000 girls.

100,000 girls a year is a drop in the bucket, if 600,000 female fetuses are aborted in that same time period. The government's program is still significant and important, but it's not going to solve the problem. And while I don't know what an average family in India spends on a dowry today, the Rs.200,000 might just be enough to offset it. It might be a practical solution, but it doesn't help a girl feel that she is being chosen as a bride on her own merits, and not because of the dowry she brings.

Because dowry, and sex selection, are secretive issues that are negotiated within the family, it is girls themselves who can know what is going on when outsiders can't. But while girls must be our allies in this, they can't do it alone. School syllabuses, for boys and girls, must educate against dowry and sex selection, if they are not doing so already. And for those girls who are brave enough to speak out against dowry and sex selection, there must be a community justice system that they can turn to.

This is a difficult time to talk about community justice systems, given the recent uproar over khap panchayats and their draconian rulings on couples marrying within the same sub-caste. (This article defines khap panchayats as community groups - usually comprising elderly men from the Jat community - that set the rules in an area comprising one or more villages).

The challenge before us is to promote community justice systems that include women's groups as representatives, and that rule in a gender-just manner on issues such as dowry, sex selection and domestic violence.

How To Spend $7.3 Billion

On a recent trip to I finally got around to reading P. Sainath's Everybody Loves A Good Drought, considered somewhat of a classic in the development sector. Between 1993 and 1995, Sainath spent months in India's poorest districts researching this book. In one of the few optimistic articles in the book, Sainath celebrates a social movement in Pudukottai district, Tamil Nadu state, that in 18 months saw over one-fourth of the rural women in the district learning to cycle.

In contrast, in his section on health Sainath describes a government system that is corrupt, lacks resources, and, in many cases, just does not function. Doctors take bribes from patients, or withhold services in the government clinics, to usher patients into their private practices. Medicine is either not available in government clinics at all, or it has been diverted to private pharmacies, again often owned by or linked to the government doctors. Doctors aside, Sainath documents a severe shortage of nurses and health workers. And in the worst cases, Primary Health Centers have been turned into cowsheds, private residences, or have just been looted for every door, frame and fitting.

The alternatives to the government system that Sainath encounters range from quacks to dissaris. At one end, many quacks have few qualifications other than a board saying 'doctor,' and are accountable to no-one. At the other end are dissaris, hereditary practitioners of traditional systems of medicine in the state of Orissa, who are a mine of knowledge on the use of local herbs and roots for some ailments, but do not have cures for others.

Reading Sainath's book reminded me of a post I had written earlier, in which I had talked about a study published in the Lancet, that found that there has been a significant drop worldwide in the number of women dying each year from pregnancy and childbirth. However, some advocates for women's health were reluctant to have the study released for fear it would reduce foreign aid for maternal health at meetings to be held in June and December. In my post I used a painting of women on bicycles by Tejuben to argue for an approach to development that does not treat women as patients or problems, but rather empowers them to lead lives that are physically active, independent and free. While an empowerment approach to development is applicable to poor men as well, I'll stick to women here.

The meeting referred to in June was most likely the G8 Summit held in Muskoka, Canada. Its Muskoka Initiative for Maternal and Child Health is a $7.3 billion package that can fund a laundry list of programs: pre-natal care; attended childbirth; postpartum care; sexual and reproductive health care and services; health education; treatment and prevention of diseases; prevention of mother-to-child transmission of HIV; immunizations; basic nutrition and relevant actions in the field of safe drinking water and sanitation. While the $7.3 billion fell short of what aid experts and NGOs were calling for, it seems that the global recession was a bigger consideration for donors than the positive news in the Lancet study. As of now, it looks like each contributing country will be able to decide on how it wants to spend its funds and there will be no coordination between them.

While a painting of women riding on bicycles can be symbolic of an empowerment approach to development, what does this mean in practice? If the $7.3 billion was to be spent using an empowerment approach, how would it be spent?

I was stimulated in my thinking by this article in Canada's Globe and Mail. The article is on a drug called misoprostol. With the exception of its use as an ulcer medicine, misoprostol is highly controversial.

When a woman delivers, if all goes well her uterus will naturally contract to close around her blood vessels. But in up to 15% of cases, the uterus can fail to contract and the woman can bleed to death within an hour. In the industrialized world, the drug oxytocin is considered the best to stop postpartum bleeding, but crucially it requires refrigeration and injection. In the developing world women have a one-in-100 chance of dying in childbirth because of postpartum bleeding.

Misoprostol can stop postpartum bleeding, and needs no cold storage or special services to deliver. Misoprostol can also be used for abortion and to induce labor. However, if misused, misoprostol can rupture the uterus, killing mother and baby.

The WHO (World Health Organization)'s position is that misoprostol can be administered by properly trained health workers, but cannot be administered locally. Yet the matter does not end there. There is a debate over who qualifies as a trained health worker, when birth attendants in poor settings tend to be relatives and neighbors of the pregnant woman. And several aid organizations have disregarded the WHO's recommendations altogether, and distribute misoprostol to women delivering.

Venture Strategies for Health and Development, founded by two physicians at the University of California at Berkeley and a health policy specialist, is one such aid organization. Dr. Potts of Venture Strategies calls the WHO's goals, of training health workers and getting more women to go to hospitals, unachievable because doctors don't want to work in rural areas. Instead, his organization gives misoprostol, with instructions, to pregnant women directly at their eight-month checkup.

Does giving misoprostol directly to pregnant women empower them? Dr. Potts seems to think so. He suggests that doctors are reluctant to have women medicate themselves because they are threatened by the notion that people can do for themselves things only doctors have done. Reading between the lines, doctors fear the loss of power in allowing women to medicate themselves. So by administering misoprostol themselves, women should gain power, which is really the meaning of empower.

However, I'm not so sure. According to this article on the Lancet study, one of the main reasons that the number of women dying from pregnancy and childbirth per year has dropped significantly in developing countries is because women are giving birth in the presence of either a doctor or trained health worker (however that may be defined).

In Orissa, for example, the same state in which Sainath documented the poor condition of the government health system, women are now given a monetary incentive to deliver children in hospitals rather than in their villages. While delivering their children in the kinds of hospitals Sainath describes is not likely to improve their chances of survival, this push by the government is being accompanied by funds through the National Rural Health Mission. There has also been discussion in the news about launching a new category of medical degree that will only allow doctors to practice in rural areas. It is hoped that this will address the shortage of doctors.

In Tamil Nadu, the fact that women are choosing to give birth in government rather than private clinics is being trumpeted loudly. Why is this something we should all celebrate? Because government clinics are, at least in theory, accountable to the people they serve. In my first job in the development sector, I was lucky enough to be exposed to an initiative to empower rural women to hold government health clinics accountable to them. Women both led their village health committees, which monitored Primary Health Centers and their sub-centers, and gained entry into committees at higher levels that oversaw these facilities. An empowerment approach to preventing maternal and child mortality to me is one that enables women to both use and, crucially, hold accountable, the government health system.

I'll end by returning to the misoprostol debate. I don't doubt that, with proper counselling, pregnant women can be trusted to use the drug safely, as they have been doing. Yet the arguments that Dr. Potts and his colleague Dr. Prata put forward for giving misoprostol directly to pregnant women are dangerous ones. If Venture Strategies is able to reach pregnant women for an eighth-month checkup, might it be possible to reach them at the time of delivery as well? I think there are better solutions to the problems of access to health facilities, whether because the facilities are not there or the women reluctant to go, than abandoning the idea altogether.