18 September 2010

Unnecessary Facades

Last week, I was in Uganda to write a story about voucher programs. In development policy circles, vouchers are all the rage. The idea is simple: Vouchers are distributed to patients, either for free or a small fee, entitling them to certain services at accredited facilities (in the case of Uganda, services for pregnant women and for the diagnosis and treatment of STIs). Health care providers are reimbursed for the cost of provision, plus a reasonable profit, after delivery has been verified.

As always, I arrived with a pile of reports in my suitcase. Their uniformity was striking: voucher schemes, they say, Empower Patients to choose where to access health services and Spur Competition among health care providers, who must entice these free-to-choose patients to their facilities.

I’d never been to Uganda before. Got the 10:05 p.m. flight out of Nairobi and landed in Entebbe after eleven. As with all late night arrivals, I felt a tired, jittery vitality, like an insomniac. Peering out the car window, my face pressed up against the glass, I strained to see out into the dark.


The next morning, a team assembled in the vacant lobby of a hotel in Mbabara: two program managers; a donor representative; and me, the analyst. We drove all morning to reach the facility, strangers, trapped in a car together for hours. At first we talked about the program, our professional backgrounds, where we come from. After an hour, the conversation waned. Turned on the radio. A preacher was talking about sin and redemption.

We stared out the windows, lost in our own thoughts, watching the fields whip by, banana trees, ant mounds, men pushing bicycles weighed down with charcoal, and others laying gravel where a new road is being built.

Arrived at the health center midday stiff and a drowsy. Shook hands with Martin, the young facility manager, who was dressed in his finest suit and polished loafers. We were wearing “field” clothes—jeans, tennis shoes.

Inside his spare concrete office, Martin said he’s worried about the women who come for antenatal visits but don’t come back for the delivery. Others refuse to be referred to higher-level facilities, even when they have life-threatening complications.

Why would they do this?

They want to be comfortable, he said. They are used to the traditional birth attendants in the village. And with referrals, some are afraid of being cut open and operated on in a strange, foreign place, and who can blame them?

Even when they want to be referred, there is no ambulance, and the rocky dirt road we traveled down for an hour in Landrovers to reach the facility is difficult to traverse. The nearest health clinic is nearly 20 kilometers away.


At another medical center, I meet four women sitting in a row on a wooden bench in the shade, each in the final stretches of pregnancy. The facility manager is encouraging: ask them questions, he says. There are four of us standing in the sun in front of them, notepads and pens in our hands. I shift uncomfortably from one foot to the other. How many babies do you have, I ask? From where did you come?

Their voices are as soft as feathers, and they bow their heads as if in prayer as they speak. I have three babies, one says. I have five, says another. I have come from 7 kilometers away. I have come from further. There is no where else to go.

At another facility, another manager takes a delegation of six of us on a tour. This is the reception, he says, the lab, the children’s ward. Then he takes us into the labor ward, guides us around a corner and proudly points to a woman with bare legs in stirrups, who is heaving, moaning, about to have her baby.

When we wonder why patients sometimes do not return to the facility to deliver when they could do so for free; when we think it is illogical to forfeit the opportunity to come to a clean, safe clinic—to sacrifice so much by not returning—maybe the patients are thinking of all they sacrifice when they do.


Kenya also has a voucher scheme, and one afternoon I visited some accredited facilities in the Nairobi slum of Korogocho. There were three of them, close to each other. I could walk between them easily.

I asked the facility managers how they would compete with the other facilities to lure patients? They downplayed the idea: we work together, they said, we don’t compete.

But you are making improvements to attract patients, aren’t you?

They said they improve their facilities first, because they are strongly encouraged to do so by the agency managing the program, and second, as a way to ensure they will be left with something when donor funds for the program run out. Facility managers in Uganda say the same thing, and for them, the latter reason is even more pressing, since donor funds for the three-year program are spent, and come next year, their new patients and income may disappear.


We give names to what our programs do for patients. Empower. Catalyze. Choice. But assessing their views, their motives, and the effect we have on them, is more difficult than is generally assumed.

Maybe vouchers empower women. Maybe they don’t. Maybe instead they are a simple subsidy for particular services at particular locations. And maybe facilities aren't upgrading infrastructure and hiring new staff out of a sense of competition.

But what is wrong with this? Patients are still coming to facilities, where the safe delivery of their babies can be nearly guaranteed. And facilities are making improvements, which make them more comfortable and responsive to patients. Moreover, these programs serve as models for governments considering health insurance programs for the poor (which both Kenya and Uganda are) but are concerned about the mechanics of accreditation and reimbursement.

Plenty of thoughtful people have questions and concerns about vouchers—about the cost and complexity of administering them versus other mechanisms to increase access; about preventing fraud and monitoring facility quality, among other things. But overall, these programs are a good thing.

Why isn’t the way things really are enough?

If You’re Ever in Juba… (A Patchwork Restaurant Guide for Travelers in Africa)

Sometimes, let’s face it, expats are annoying. Some of us adopt pseudo accents. We occasionally (and with dramatic flair) blame our bad habits on the countries we live in (you’d drink too if you’d seen what I’ve seen). We act superior when we are home. An innocent trip to the grocery store can get you an ear full on overabundance and consumption.

Lately, I’ve been catching myself doing another such annoying thing, something that even annoys other expats. The conversations go like this:

Friend: Want to grab dinner?

Me: Sure. Where should we go?

Friend: Maybe pizza?

Me: But there’s no good pizza here. Let me tell you where you can get REALLY good pizza. Have you ever been to south Sudan? (At this point my friend has stopped listening because she thinks I’m being just a little show-offy.)

Annoying though it may be, in the spirit of eating well in far flung places, I’ve put together this handy restaurant guide based on the cities I’ve lately traveled to. Let me be clear: I haven’t spent long periods of time in any of these places, except for Tanzania, so you may find lots of phase 1 restaurants (i.e., the places where the wazungu go when they don’t know where the really good places are). If so, apologies. Pease add to it—consider it a public service for expats and travelers everywhere.

Dar es Salaam

There are many things to love about Tanzania. The sun, the sand, the gentle sway of palm trees in the moonlight. Quick jaunts to Zanzibar in tiny toy airplanes piloted by 26-year olds nursing blistering hangovers. Ficken.*

Yes, there is much to love. But the gourmet traveler may find Dar wanting. Nonetheless, here's a random sampling of some of my favorite places to eat:

Zuane—Okay, it’s all relative, right, but for Dar, this is pretty good Italian food. Dine al fresco on the veranda lit with lanterns and pictures of Italian people from the 1940s on the wall. The pasta isn’t the highlight: try the pizza. The Zuane is especially good. Also, this may be the one place in Dar that serves a FREE appetizer (bread with bruschetta).

Sweet Eazy—Also known as the Sweet Sleazy (for a certain, ahem, clientele that frequent the place in the small hours), this rooftop restaurant, with tables beneath a canopy of trees, serves a nice mix of sea food and has a sleek indoor club section with great live music on Thursday nights.

The Patel Brotherhood—Not as scary as it sounds, this Indian restaurant, situated alongside badminton and tennis courts, serves great, cheap Indian food. Most of the members and guests are local Indian families, and there are usually kids running around, and men sitting in far off corners smoking and talking quietly. Some nights, a projector is set up to beam cricket or football. You’ll also hear the call to prayer from a mosque nearby.

Rehobot—This is a great Ethiopian restaurant in the backyard of the woman who used to be the head chef at the other Ethiopian restaurant in Dar, Addis in Dar, but left to start her own business. (Snap!) It’s small (you literally walk through their living room to go to the bathroom), charming and inexpensive. Plus her husband makes great furniture.

Slipway—Now four months ago I would not have recommended Slipway to anyone. It always struck me as a fly-infested tourist trap. BUT, since the restaurant/bar renovation, I’m in love. Wide open tables, comfy couches, right on the water, it’s the best place for a drink to watch the sun go down. The food isn’t great, but watching the fisherman sail their Dhows in for the evening completely makes up for it.

Africafe—I bet some of you thought I was going to say that Epi DÓr was my favorite café in Dar, but you would be wrong! Granted, I spent every other day of my first six months in Tanzania at Epi DÓr—and the croissants are lovely—but they keep raising their prices and aren’t super nice to their staff. Go instead to Africafe up by Seacliff, where they have even better coffee, better music (not that I don’t LOVE Celene Dion and Michael Bolton on a loop) and occasionally, drum roll: free wireless internet. But only occasionally. When they remember to pay their bills. Don’t push your luck, ok?

New Kibo Business—If you’re in the mood for some local fare, try this pub nestled in the working class Kinondoni neighborhood of Morocco. Good mishkaki and beer, especially when there’s power.

*Chickens are often fed fish meal in Tanzania, which causes ficken, the dreaded by all experience of confronting a slightly fishy taste when you bite into your chicken sandwich. The horror.


Osteria del Chianti—Now there are two Osteria’s in Nairobi. You want to go to the one with the gelato shop outside, not the one in Westlands by the mall. This restaurant is the MOST charming, the COZIEST, the BESTEST Italian restaurant in Nairobi, with a smoldering fireplace inside and a warm glow of candles and lanterns outside. Good for long, meandering conversations over wine. Get the pasta with fresh tomatoes and basil. Delicious.

The River Cafe—Off Limuru Road, near Village Market, this place is also LOVELY. Really, really lovely. Tables nestled between gardens, grassy hills and a pond, surrounded by flowers and bougainvillea, the place feels like a bit of Eden in big, hectic Nairobi. Their breakfasts are delicious. Try the eggs benedict or eggs with grilled tomatoes.

Java House—Saying you like Java House in East Africa is a little like saying you like Starbucks in Seattle. Totally UNCOOL. But we’ve got to face facts: the coffee house chain is pretty damn great. First, most outlets offer free wireless internet. This is gold. Second: they serve Mexican food. Now granted, it’s Africa Mexican food, but hell. It’s been a long time. I’ll take what I can get.

Havana Bar—First question: why is there a Havana bar in every African capital (see Juba and Bujumbura below)? But to the point, this Westland not-so-divey dive bar is fun for a drink and people watching. Dimly lit and smoky, with walls painted cherry red, the music is loud, and the drinks are good. And if you get bored, there are a random smattering of bars all within stumbling (I mean walking) distance.

Addis Ababa

Lime Tree Café—Hands down, the best. Macchiatos to die for. Free wireless. Good music. And you can get a pedicure at the spa downstairs.

Top View—Up the hill from the Megenagna Roundabout, the view of Addis from this place is amazing (and the food is delicious to boot). The only place with a better view of the city is on the steps of the Orthodox church on top of Entoto mountain. Take a mini bus from the market, and slowly wind up and up the narrow road, through the foothills densely covered with eucalyptus trees, to the top of Entoto, over 10,000 feet up, in the clouds.

(Anyone have anything to add for Addis?)


Think fifty years of civil war are going to stop Juba, the capital of the soon-to-be-new-country, South Sudan from making the “patchwork restaurant guide” list? No way! South Sudan may be one of the most under-developed places on Earth, but they do have a few awesome restaurants.

Da Vinci—This mixed fare restaurant is expensive, but located right on the banks of the Nile, it’s worth it. Just down the river is the one bridge in Juba, which trucks traverse to bring goods in from Kampala in the south. At twilight, under the mango trees, when the Nile is silvery and calm, Da Vinci may be one of the most enchanting places in Africa.

Logali House—If you’re in the mood for something vaguely neocolonial, check out the restaurant and bar at Logali House, a charming boutique hotel definitely stands out amidst a sea of tents and containers in Juba. Their veranda is a great place to watch the game and have a glass of wine, but as with everywhere else in Juba, it’ll cost you. A burger runs about $18. The vege lasagna is particularly good and costs about the same.

Afex—This is actually a U.S. compound that started as a tent camp. They still have the tents, along with cottages for USAID contractors (that run about US$5,000-8,000 per month—hello aid dollars hard at work), but there is also a great buffet restaurant that is open to the public. Enjoy the burrito bar and mingle with some friendly neighborhood Blackwater contractors (I mean XE).

Havana—Right next door to Logali, this is where the Cuban-Jubans hang. A group of former Sudanese exiles—doctors, engineers, economists—started the place. They gather to share a bottle of whisky and talk, very often in Spanish, about the days when they were educated in Cuba during the civil war and. Havana has great pizza: try the pumpkin with fontina cheese.


Rumors of coups and post-election violence hover like smoke over the tiny central African capital, but civil strife aside, Bujumbura is a culinary jewel.

Bora Bora—A Saturday afternoon at Bora Bora and you’ll consider retiring in Burundi. A stylish beach shack /bar/cafe/restaurant on the shores of Lake Tanganyika, you can chill out on wide couches by the pool and listen to mellow reggae tunes. Try the avocados with prawns.

Havana—This nightclub and lounge is sleek and stylish, the place to be seen on the weekends. Also a great spot to grab a beer and watch the game after a long day at the office fighting poverty.

Botanika—With candle light and palm trees swaying in the evening breeze, the quiet murmur of conversation and chink of wine glasses, this restaurant oozes intimacy, and the steak and chocolate mousse are amazing. (Alas, good wine is hard to come by in Bujumbura, but you will make due at this place.)

L’Archipel (and) Kiboko Grill—Both places have great Belgian fish dishes, with tables outside in the garden. Kiboko is set on the grounds of Ubuntu Residence, a charming inn on the lake, which has some of the warmest, friendliest staff in Bujumbura. Say hi to Blandine when you go.



01 September 2010

Groping for Relevance in Journalism*

It’s no secret that the journalism business—newspapers especially—is in the dumps. Profits are sinking, circulation keeps plummeting, and opinion polls show distrust in the media is growing: in 2009, the Pew Research Center found that only 29 percent of Americans say that news organizations generally get the facts straight, while 63 percent say that news stories are often inaccurate. (Read longtime journalist James Fallows chapter Why We Hate the Media, in Breaking the News: How the Media Undermine American Democracy, for thoughts on why).

None of this is new. I remember attending a meeting when I worked at the San Diego Union-Tribune, in which one of the editors said that the simple habit of reading newspapers was “the only thing keeping this industry from a free-fall.” For a kid just starting out in the business (this was in 2003) it was crushing.

According to various studies, the number of newspaper editorial employees, which numbered more than 60,000 in 1992, fell to around 40,000 in 2009 (see CJR piece referenced below). Circulation has been on the decline since the 1940s.

Many blame the Internet, Google especially, for siphoning content, but Fallows disagrees: “If Google had never been invented, changes in commuting patterns, the coming of 24-hour TV news and online information sites that make a newspaper’s information stale before it appears, the general busyness of life, and many other factors would have created major problems for newspapers.”

“Journalism isn’t necessarily dying,” says a journalist friend at the New Yorker, “[but] the business model that supports it is. I don’t generally advise people to go into it. Most of my colleagues are thinking through their own Plan Bs. It’s a scary time.”

I don’t have the expertise to lay out all the various problems and potential solutions. For that read James Fallows’ June 2010 piece in the Atlantic, How to Save the News and the recent Economist interview with Jay Rosen, a professor of journalism at New York University and author of What Are Journalists For?

But let’s talk about reporting on Africa. The consensus, based on conversations in the dozen or so countries where I’ve traveled, is that it is woeful. Lazy. Inept. Misleading. Sensational. Cavalier. Dishonest. Out of touch. (There are notable exceptions such as Celia Dugger at the New York Times, The Guardian (UK) and others).

Weak international coverage is also not a new phenomenon (although hard financial times have seen newspapers trimming and/or closing foreign bureaus and an increasing reliance on syndication). This was, after all, what spurred Ted Turner to start CNN—to provide better coverage of non-Western countries.

But the bottom line is, in an increasingly interconnected world, coverage, particularly of Africa, is pitiful.

“I have no idea where I would turn to if I wanted good information on Africa,” says a journalist friend. This is a BIG problem.

But it is a problem that has spawned a sort of new journalism: Africa-hands don’t read mainstream newspapers to get their news about Africa (although we read them for fun and so that we can blog about how bad they are). We read the blogs of other Africa hands, and the kind of specialized reporting that I do for various international agencies and think tanks. In this space, there is a mix of content: some of it is great, a lot of it is mediocre.

Even if the new journalism was amazing, it wouldn't be enough. Trained journalists have a critically important civic role to play, holding those in power to account and providing information and analysis to help average citizens participate in civic life.

“Something is gained when reporting, analysis, and investigation are pursued collaboratively by stable organizations that can facilitate regular reporting by experienced journalists, support them with money, logistics, and legal services, and present their work to a large public,” say Leonard Downie and Michael Schudson in “The Reconstruction of American Journalism” in the Columbia Journalism Review.

Newspapers can, and will, find a way to cope with the challenges. For ideas on how to generate revenue, read Fallows and also Downie and Schudson, who recommend, among other things, that the IRS or Congress authorize independent news organizations that are “substantially devoted to reporting on public affairs to be created as or converted into a nonprofit entity or a low-profit Limited Liability Corporation serving the public interest, regardless of its mix of financial support, including commercial sponsorship and advertising.”

Shutting down print operations, as the Seattle Post-Intelligencer and many others have done, is probably a good thing for many newspapers (think about the cost of making those enormous rolls of paper, shipping them, the expensive machinery that makes newspapers, delivering them door to door, and doing that everyday). They should also retain their reporting and editorial staff and pay them well—they are newspapers’ most valuable assets.

But maybe the biggest task is to convince people to believe, like we used to, that solid, trustworthy news is worth paying a small fee for. You give a little and get a lot.

But for this to happen, newspapers need to improve their content. In his Atlantic piece, Fallows recounts a conversation he had with the executive who started Google News. As the executive scanned tens of thousands of headlines a day:

“[H]e said that what astonished him was the predictable and pack-like response of most of the world’s news outlets to most stories. … their conventions and instincts made them all emphasize the same things… [which] indicated a faddishness of coverage…and a redundancy that journalism could no longer afford. ‘I believe the news industry is finding that it will not be able to sustain producing highly similar articles.’”

Newspapers must be willing to take smart risks. The New York Times has a gigantic global readership. Jeffrey Gettleman, their swashbuckling Nairobi bureau chief, writes about 80 percent of their East/Central Africa coverage. This means that, to the extent people get their news about Africa from the Times, one man is telling and shaping the story. News agencies must stop relying on the usual suspects and tap into the huge pool of hungry young journalists who are willing to put in long hours and work for practically nothing. They should broaden their reporting pool and publish unconventional pieces that are fresh, thoughtful, informative and interesting.

“It just seems to me," says Dean Nelson, a San Diego-based journalist, "that we’re in the same place we were a couple hundred years ago when there were dozens of newspapers in every city, each of them perpetuating the political voices that were supporting them. Journalism in America started out as pamphleteering, and now that everyone is a blogger/journalist, we’re back to where we were. Then, when the penny press came along and figured out a way to publish news more cheaply, things changed dramatically. We’re in that era now, where people are trying to figure out how to inform the public, protect democracy, AND make some money. In the meantime, a lot of journalism will continue to be done badly, with the exception of a few outlets who can stand to lose some money while it gets sorted out.”

*This title is based on Eugene Goodwin/Ron Smith’s Groping for Ethics in Journalism, a must read for any journalism student.