Subscribe
Share
Share
Embed
Welcome to GiveWell’s podcast sharing the latest updates on our work. Tune in for conversations with GiveWell staff members discussing current priorities of our Research team and recent developments in the global health landscape.
Elie Hassenfeld: [00:00:00] This is Elie. I'm sitting here with Teryn.
We're just at the beginning of our second to last day of the trip before we head back. And today, we're going to visit an informal settlement in Lilongwe, which is the capital of Malawi. And we sort of started our trip in the southernmost large city of Malawi, Blantyre.
And we were looking at spending time in rural areas and got to spend time in talking to people who are living in rural poverty. As we came into Lilongwe and sort of outside it, like on the way to more dense settlements and something that's not quite urban, but also not quite rural. And then today we'll get a chance to understand more about urban poverty in Lilongwe to help get a better picture of what life is like here. So Teryn, what's on your mind as you think about that for today?
Teryn Mattox: Yeah, so I guess I was struck initially at the first few villages we visited, that were in really rural areas that, [00:01:00] yes, these people are incredibly poor, living on very slim margins, but also, they all had gardens, they all had productive livestock in one way or another, and had this community of individuals that were taking care of each other. And, it felt like there was a social fabric that was relatively strong and there were some redundancies in terms of like, if this garden fails, I've got a chicken, et cetera.
And then as we got closer to Lilongwe, like yesterday, we visited these villages and one was very close to town, and the folks in that village had sold off most of their land to people from Lilongwe proper, who were essentially speculating on land right outside of the capital. And there were no gardens and there was no livestock because all of that extra land had been sold away. And in fact, there were some people who had become landless and needed to move or were renting their place because of that.
And it feels like both, there's like a lot more opportunity [00:02:00] closer to the capital. These folks had access to a functioning hospital with lots of medicines and could build businesses to sell to folks in the city. But then also were in this process of kind of like divesting from all of these traditional assets that had given them some sort of a safety net.
So I think it'll be interesting to see as we're in town talking to folks that are in these informal settlements that might have gone through this process of selling all of their lands or, you know, coming to the city for more opportunity, but that maybe don't have access to all of those same social structures, asset structures that were available in the rural villages.
Elie Hassenfeld: Yeah, I'm really interested to ask people, what brought them to the city? Because, I got to speak to a ton of people yesterday and I asked them, who's in your household? How many children do you have? And when they had adult children, we would ask them, where did their children go?
I don't think that any of them said that they had moved to the city for opportunity. We heard about people who had moved to Mozambique, which is a neighboring country, because they thought there'd be more farmland there, to your point. And [00:03:00] we had seen some evidence, though I think not to the extent that you did, of people selling off farmland to people from the city.
One of the ways that our translator identified that was that there were large houses, like really large houses, being built. And so that must be the wealthier people from Lilongwe who have purchased land to build a larger house here, in proximity to the city but not right in the city.
But no one said that their children had gone to the city to seek opportunity. And I feel like there's this general narrative or impression I have that, you know, sometimes people move from rural areas to urban areas to seek opportunity in urban areas. And I wonder if that is part of the story we hear today, or if maybe we'll hear a different story, which is, like, I couldn't make ends meet. I didn't have enough food because of something that happened in rural areas and it forced me to move to the city. And obviously we won't be doing a systematic study, but I'm really curious about the extent to which we hear the sort of "forced here" versus "I chose to come here because I thought it would be better for me."
Teryn Mattox: Well, it's all kind of a cycle, right? The work that the folks [00:04:00] in this village were taking on was more piecework, right. So, you know, as you're losing access to land, you are kind of forced into these areas where you can get more piecework, which is in the city.
Elie Hassenfeld: Yeah. I guess I could also imagine a story where people say, I proactively moved to the city because I think there's more opportunity and that's to climb the economic ladder. But I don't know. We'll see. I'm really interested to see that.
--
Elie Hassenfeld: We visited a school that was made up of three or four large buildings that seemed to consist of a library, a main classroom building, a dormitory, and then a high school, situated around a fairly large yard, perhaps the size of a football field. We spent a few hours there speaking with school representatives and students before heading out to the community to visit some families who had previously agreed to meet with us.
This community was very different from the communities that we had visited previously because it was an urban community. And so, where in visits to the rural areas, there had often been one or two homes [00:05:00] every hundred feet or so, here, we looked out and saw many, many homes right next to each other, abutting the grounds of the school.
And during our time at the school, one of the representatives who walked us around had children in the school. He was also a member of the parent-teacher association at the school. And we were able to talk to him about his experience with the school and his life in the surrounding community. This is some of what this gentleman shared with me.
--
Elie Hassenfeld: Okay, so you said you have three kids here?
Community Parent: Yes. Three kids.
Elie Hassenfeld: So one was age 13 in secondary school?
Community Parent: Yes. And the other one is 15 at secondary school, so starting form four, and the other one is nine. She's at the primary school.
Elie Hassenfeld: And is form four the last . . .
Community Parent: It's the last year here at the school level. It's the last one, form four.
Elie Hassenfeld: Oh, wow.
Community Parent: And after that is when they graduate maybe to universities.
Elie Hassenfeld: Wow. Is that very young, to be in form four and go to university age 15?
Community Parent: No. It's just normal.
Elie Hassenfeld: That's just normal.
Community Parent: Yeah. Just normal.
Elie Hassenfeld: Do [00:06:00] you know which university she'll go to?
Community Parent: I don't know yet. Because it depends according to how she is going to qualify.
Elie Hassenfeld: What would be your top hope or choice?
Community Parent: Yes, my favorite is if she'll go to agriculture.
Elie Hassenfeld: Agriculture.
Community Parent: Yeah. Agriculture. Her dream is to go to Bunda College where they learn agriculture.
Elie Hassenfeld: Okay. So I guess we're standing on the school grounds now, and this is the secondary school building. And we saw the library and the cafeteria and the primary school. And then you live beyond this wall?
Community Parent: Yes.
Elie Hassenfeld: How far from here do you live?
Community Parent: Yeah, it's just like maybe 500 meters away.
Elie Hassenfeld: 500 meters away?
Community Parent: Yeah.
Elie Hassenfeld: Have you lived there for a long time?
Community Parent: Yes, I've been there for about nine years. Because I'm working somewhere, I just wanted to be near to my workplace.
Elie Hassenfeld: What was the job that brought you here?
Community Parent: My job is at JTI, Japanese Tobacco International.
Elie Hassenfeld: Japanese Tobacco International.
Community Parent: Yeah. Yeah.
Elie Hassenfeld: What kind of work do you do with them?
Community Parent: Yeah, I am a driver.
Elie Hassenfeld: A driver?
Community Parent: Yes sir.
Elie Hassenfeld: OK. And so how often do you work?
Community Parent: Yeah, I work in a [00:07:00] seasonal contract. We renew every year.
Elie Hassenfeld: Every year.
Community Parent: Yes. Every year you have to renew the contract.
Elie Hassenfeld: And do you work every day, or only drive some days?
Community Parent: Yeah, I work from Monday to Friday.
Elie Hassenfeld: What time do you work?
Community Parent: Normally we go to work at 7:30 and knock off at 5:30.
Elie Hassenfeld: 5:30.
Community Parent: 5:30, yes.
Elie Hassenfeld: How do you like that job?
Community Parent: I like it because it's where I get my everyday living. It's where I get my salary to help my family.
Elie Hassenfeld: And when you were born, what did your family do for income?
Community Parent: Okay, for income, like my mama, she was working with a minister of forests. And my father at that time, he was a primary teacher.
Elie Hassenfeld: A teacher.
Community Parent: Yeah, he was a primary teacher.
Elie Hassenfeld: And so was that in Lilongwe where you were born?
Community Parent: Yes, I was born in Lilongwe.
Elie Hassenfeld: Did you go to, like, what kind of school did you go to when you grew up?
Community Parent: My school?
Elie Hassenfeld: Yeah.
Community Parent: I started my primary school at Njewa primary school, that side.
Elie Hassenfeld: And is that a government . . .
Community Parent: Government primary school. [00:08:00] Okay. Where we have many kids there. So we had none of the opportunity like our kids having here to go to the nearest school, which is better, like this one.
Elie Hassenfeld: What are the biggest differences you think between the school you went to and the school that your children go to?
Community Parent: I think my children as they come here, I think this is the best school for them. The difference is that school, we are just going maybe to the school with empty stomach. And going there maybe . . .
Elie Hassenfeld: So you were hungry when you were there?
Community Parent: Yes. Like that. Even you cannot even concentrate to the teacher. You are hungry. And even sometimes for me to be recognized by the teachers, because it's congested, a lot of kids.
Elie Hassenfeld: How many kids would be in a classroom?
Community Parent: Like in the classroom instead of being 45 kids, we are maybe having 60 kids. And even learning under the tree.
Elie Hassenfeld: Oh. Because you just didn't have enough space. So here there's like 45 kids, right?
Community Parent: Here, like I think 45 to 40 kids in the class. So, yeah. [00:09:00] A teacher is able to recognize if someone is misbehaving or even if someone is making noise. A teacher say, yeah, you stop there. But if in the congested one, someone might be making noises but the teacher cannot recognize.
Elie Hassenfeld: Okay, so those are the big two. One is that there's food for breakfast, which is a big, big deal. And then the second is it's less congested for the teachers.
Community Parent: Yes. And even the quality of education. Yeah, the quality.
Elie Hassenfeld: Do you think your daughter, after she graduates college, she'll live in Kauma?
Community Parent: Probably. She might be staying here. Or maybe to my home village at Njewa there, maybe she might go back. And once she grows up, she'll have the choice. She'll have a choice.
Elie Hassenfeld: Of the people who live in Kauma, do you think most of them are from Lilongwe or are there some that come from further away?
Community Parent: Many of them, they're from Lilongwe. And they're from within the village. They're working maybe in the like area 10, 43. Maybe they're cooks, or they're [00:10:00] guards or whatever, so they're staying there. So many of them, most also come here because of their job.
Elie Hassenfeld: What do you think, just thinking about the community, are the biggest challenges or the problems that face people in the community?
Community Parent: Most of the challenges is poverty. You know, some of them, they're not well-educated. So if you're not well-educated here in Malawi, it's a big problem. So you find these, not the white-collar jobs, these jobs like guards, maybe cleaners, gardeners. Yeah.
Elie Hassenfeld: And so it's just hard for them to find those jobs and to make money.
Community Parent: Yeah. They don't make a lot of money for those jobs.
Elie Hassenfeld: When your children have been sick, where do you take them if they get sick or something?
Community Parent: If they get sick, most of the times when they get sick while they're at school here, we have a nurse here. She tries her best. Then afterwards, we have to go maybe to other community clinics. And when you go there, they find that, oh no, we cannot, [00:11:00] we are not able to treat this. Maybe you just go and find the medicine, maybe to the pharmacist. Maybe you buy the medicine somewhere there.
Elie Hassenfeld: So often you go to the health clinic and they can tell you what medicine you need, but then . . .
Community Parent: If you don't have money, just leave your kid maybe suffering if you don't have money to buy the medicine.
Elie Hassenfeld: What kinds of medicine do you usually need to buy?
Community Parent: Most of the times here, it's for the malaria. Because in this community, malaria is the problem, cough is the problem. So that's the kind of . . .
Elie Hassenfeld: Do you know how much that costs to get malaria medicine at the private clinic?
Community Parent: Yeah, for the malaria. Once I bought at a certain pharmacy there. It was the dosage, it was around 35,000 kwacha for her. That's for seven days for malaria.
Elie Hassenfeld: Well, thank you so much for talking to me and answering questions. I appreciate it; that's nice of you.
--
Elie Hassenfeld: So today we visited a school and then were able to see some families [00:12:00] living in an urban settlement in Lilongwe. And a lot of the work that GiveWell has funded in our time has been in rural areas, and so it's interesting to be in an urban area. And, you know, we were just reflecting on some of the biggest differences we noticed between the area we're in today and areas we've been earlier this week. So, Teryn, what were some of the things that you noticed the biggest differences between the urban area and the rural areas that popped out to you?
Teryn Mattox: Well, it was like a totally different world. In the settlement that we were in, the houses were very close together, people didn't have land, many people were renting and working, like doing piece labor. It seemed like there was a lot of different types of jobs that were available. So people had different types of opportunities, certainly different than we observed in the villages.
Elie Hassenfeld: What kinds of opportunities, like what were the different kinds of work that people brought up?
Teryn Mattox: Yeah, so it's interesting, we started the day at a school and then some of the students from the school brought us to their homes. So one of the students brought me to his home, and every member of his family [00:13:00] was engaged in some sort of income-generating activity.
The mother ran a water kiosk where, again, because you're buying your inputs, many people from the community were going to buy their water. One of the sisters was a chef in a restaurant. Another sister was going to college for agriculture. The son was carrying maize from one place to another. So they're just like a lot of different kinds of work.
Elie Hassenfeld: Julie, what did you notice?
Julie Faller: Yeah, I think I noticed many of the things that were similar to Teryn. One thing that came through with talking to the households where I visited was that each of them also had connections back to their home villages, which were in more rural areas.
And so in both these cases, the working-age parent had come to Lilongwe seeking more of those opportunities that Teryn had talked about, but they maintained a connection with their village, in some cases, they had gone back and forth at different life stages. And they kind of drew out the point that it's a lot cheaper in the village, but that there was more opportunity to make a living here in Lilongwe.
Elie Hassenfeld: Yeah, I mean, one thing we heard a [00:14:00] couple times was that in the village people were farmers, and if they were farmers, then they, in a good year, would have this huge income spike once a year. But then really not have that much money the rest of the year. And, you know, in a bad year it could be really problematic.
Versus the city where they just had more consistent income all along, but also had to pay for a lot of things like, had to pay for water, weren't growing food, so had to pay for food. And that just meant that it was hard to have enough money to survive, like just kind of doing the basics was really challenging.
Teryn Mattox: It might've been the season that we were in the villages, but I didn't come across a household in the villages that had gone without food for multiple days. But one of the households I visited today had at least claimed that none of her children had been able to eat for three days. So that felt like a difference. And again, it might be because it was the rainy season out in the villages, and maybe it's worse other times of the year.
Elie Hassenfeld: We even heard yesterday a story where someone said, we didn't have enough food, we couldn't eat, but we sent our [00:15:00] children to the neighbors. And so there was, I don't know, there's something—I mean, of course we're talking about just a few people and so who knows—but certainly like some possibility that there was more of a social safety net in a sense in the village relative to the urban environment.
Julie Faller: Yeah, and I think another thing that came through was just that the economics are really difficult. We were talking with somebody who said that she earned 90,000 kwacha a month at her job as a water kiosk vendor.
And then she had two children in secondary school, one of whom had a scholarship. But with those two children, 45,000 kwacha went just to school fees. And then that left, you know, the remainder for rent and for food and for clothes for the kids and for school materials as well. And so just drawing out again that even with that income, if you're also paying for everything, it's just difficult.
Elie Hassenfeld: Yeah. We heard something similar where someone's salary had been raised from 80,000 kwacha a month to 120,000 kwacha a month. It had just happened, but Malawian inflation has been 30% per year for the last three years. And so, I don't know how [00:16:00] often his salary was raised, but it easily could have just been catching up to basic cost of living adjustment that had to be really large.
Something we've just heard so many times from basically everyone we talked to this whole trip is how expensive things are. And it wasn't really clear how to interpret that, but I think one reasonable interpretation is just inflation has been really high. And at 30% per year over a very short period of time, prices are gonna be much higher than you remember them being, and that will happen consistently.
These are some of the things we saw today that were differences in an urban environment versus a rural environment, which is really helpful because we'd spent so much time in rural environments this week.
--
Elie Hassenfeld: The next day was our last day in this trip to Malawi. On the way to the airport that morning, we made one last stop, which was to a major hospital in Lilongwe, the capital city of Malawi.
This facility represented the highest standard of care in the country. And it gave us the opportunity to meet with staff and try to understand how recent cuts to foreign aid were impacting this [00:17:00] relatively well-resourced urban facility. Relatively, compared to many of the other facilities that we had seen in this trip.
As we waited for our flights a few hours later, we found a corner in the airport to debrief and share thoughts on what we had seen and heard during that visit to the hospital.
--
Elie Hassenfeld: We're at the airport just heading home from our trip. Today, we visited a hospital where we were able to talk to hospital administrators and also members of an implementing partner that focuses on HIV/AIDS, about the experience of the funding cuts and what they did earlier this year, and then their plans for how to respond and what it might mean for the future.
And so I'm here with Julie. Julie, what did you think of the stories they told of what it was like to hear about the funding cuts and how they responded?
Julie Faller: Yeah, so I think we got a really concrete sense of how disorienting and chaotic it must have been when this news came down. The clinician who we were talking with told us that basically, on the day that they heard [00:18:00] about the cuts, patients were already arriving at the hospital expecting to receive their HIV treatment, and then they had a staff meeting and were told the stop work order has come down.
They were very surprised because they had heard about the waivers for essential or lifesaving care, and they understood themselves to be part of it. And then they got the news like, no, you're not. And they said, staff have to go home today, telling the patients that they're not going to get treatment right away.
And the description of trying to bring in a skeleton crew of staff from elsewhere in the hospital, yeah, it really struck me, Elie, when he was saying, bringing people who aren't trained and they were like looking at, you know, trying to see are these bottles of medicine the same, kind of holding up and comparing two different treatments, and trying to figure out how to do this whole treatment protocol that just wasn't part of their day-to-day work.
Elie Hassenfeld: Right. You described this as a meeting at nine, everyone had to go home at 12. And then, I guess he said something like two weeks later they brought back a skeleton crew. This was like 10 of the staff that had been trained to help and then later, maybe [00:19:00] a month or six weeks later, more staff were able to return to help out.
But in those first two weeks, it was just like they had a meeting, a few hours later they were gone. And then people who weren't doing this regularly had to just continue to treat patients, which just sounds, really, I mean, he said "chaotic" many times, which is understandable.
Julie Faller: Right. And one thing that was consistent with what we'd heard from other people too was that then they had to try to counter this sort of misinformation. People came to the clinic and there weren't staff available, and then a rumor spread or the news spread that you couldn't get your treatments, that there weren't treatments available. And so once they did have more staff, they had to try to tell people like, no, you can come, you can get your treatments.
Elie Hassenfeld: Right. So people thought the drugs themselves weren't there. In fact, they said they always had the drugs, but they weren't always able to meet the demand with staff because people were telling others that the drugs weren't there.
Julie Faller: And then I think that my other big takeaway was just thinking about what's coming next and what they're planning for.
Elie Hassenfeld: There were like these other stories that they told that I thought were like consistent with other things that we heard this week. So, you know, one thing they [00:20:00] talked about is the hospital was already short staffed, and I think he said they had a 60% vacancy rate for nurses.
Julie Faller: Right.
Elie Hassenfeld: Which I took to mean, ideally they wanna fill all these positions. And they're not filling them because they don't have the funding to fill them. So that just gives you a sense of the fact that this institution is short staffed relative to the care they want to provide.
And then they had to take from that limited staff and move them over to focus on providing HIV treatment. And that just meant that it had these downstream effects on the hospital because those staff had been doing something else.
He also talked about the fact that members of staff at the hospital had been going out and doing community outreach. And with the cuts, they didn't have enough funding for fuel, and so they couldn't send people out into the community in the way that they did before.
And that just meant that the work that they were doing to reach people closer to where they were, to increase the likelihood that people would be treated and know that they could get treated was reduced because they were bringing those staff [00:21:00] in—both because they didn't have funding for fuel and because they needed to use them for the onsite services.
Julie Faller: Right. And he said one implication of that was then that complicated cases that might have been able to be treated closer to their home. Because the specialist couldn't travel out, they were saying send those people to this hospital. And it just meant more strain on the hospital's resources, ultimately in the form of more patients.
Elie Hassenfeld: Right. And then there was this other manifestation where, you know, they had to triage and said, well, even with all these changes, we still can't treat everyone who would otherwise be coming here. And he explained that sometimes people would travel extremely long distances to this hospital because they wanted to get away from home because of the stigma of being seen accessing HIV treatment.
And he said people would travel 300 kilometers. I mean, we don't know if that distance is exactly right, but very long distances, to be in a large, more anonymous hospital, more anonymous location. And now because they've decided that they can only treat a certain number, they've said don't come here, be treated closer to home. [00:22:00] And I think we don't know the effects of asking people to go somewhere that they otherwise, you know, they were willing to travel very far distances to avoid being seen at their local facility. And I think it's just unclear what that means for their care-seeking going forward.
Julie Faller: Yes.
Elie Hassenfeld: I mean, I think a lot of these examples are consistent with things we've heard across the week of just, I mean, making like really tough choices in a really difficult situation, prioritizing near-term, necessary treatment over ongoing prevention. And I think, you know, some of the people again today said, you know, we're really worried about what this means for the next couple of years as the effects of reducing prevention activity flow through.
Julie Faller: Yeah, so the implementing organization that we were talking with, now they're back up to previous operating levels, but they're anticipating a potential cut to their budget after the next budget cycle starting in October.
So they were telling us about their plan, which involves basically significantly cutting staff and, as a result, cutting a lot of the activities so that they would, try [00:23:00] to shift responsibility for key outreach tasks and also care of patients who are more stable to the Ministry of Health system, the routine healthcare system, and that this implementing organization would focus on more complicated cases, the people who need really specialized care.
And that just raises a lot of questions about how will it go when you try to move these quite complex activities, part of a system that's been built up over decades, to an already resource-constrained system.
Elie Hassenfeld: I mean one thing that also hit home for me, just in the experience of being there, is like sometimes when we think about funding cuts, we're just like, there's going to be this cut, that's going to be really bad. It almost feels abstract—the fact that there'll be this large cut. And in this implementing partner that we visited with, they have hundreds of employees, and currently these employees expect that like half of them roughly are going to lose their jobs in two months.
I think it's worth imagining how difficult it would be to come [00:24:00] to work every day to deliver care with the expectation that you're out of a job in two months. And especially in a context where it's really important to have a job. I mean, we've been talking all week about the challenges of, you know, the economy and having enough money for food.
I mean, I think it's clear from just visiting that many of the staff themselves are extremely low income and just coming in every day with the expectation that two months from now, their employment is terminated, which just, I don't know, it sort of adds to the overwhelming difficulty of the situation.
Julie Faller: Yeah. That came through to me, and then another thing is just like a squandering of progress. Like you walk around, and we saw the patient flow, and it had everything from like, you know, making sure that if you have a secondary infection, you see a nurse about that. For patients who aren't responding to first-line treatments, there's a place to go for that. For screenings for types of cancer that disproportionately affect people with HIV, there's a place to go for that. They have really built up a system that can deal with the complexities [00:25:00] of this disease. And thinking about how much of that whole system wouldn't be able to be sustained under a much tighter budget.
Elie Hassenfeld: Yeah. So I think this last visit to the hospital was a nice capstone for our trip. We heard a lot of similar things today to what we'd heard earlier this week that there was a period of incredible difficulty while organizations and government facilities tried to respond to a pause in funding, that it's just like incredibly depressing that there's been so much progress, and it's really unclear how this will work going forward.
And there are just a lot of people who are really, you know, both practitioners and patients, just like really struggling with what is an incredibly challenging situation.
--
Elie Hassenfeld: Hey, this is Elie. It's been about a week since we got back from our trip to Malawi, and Teryn, Steven, Julie, and I were just sitting down [00:26:00] and reflecting on some of our takeaways. Two of our big focuses for the trip were understanding the role that aid cuts played on the health system in Malawi, and learning more about what life is like there, especially to inform our increased work on livelihoods programs.
So one of the big things that we saw consistently, and was really salient to me, was the way in which Malawi had responded to aid cuts by shifting resources away from community outreach, which is essentially preventative health services in farther-flung areas, to bring those health workers back into facilities where they could provide care at hospitals, you know, distributing HIV drugs and HIV testing.
And it seemed like that shift was a major way that Malawi responded to the cuts. And anyhow, that was something we saw over and over again throughout the facilities that we visited.
Teryn Mattox: Yeah, and what you're describing is kind of the reaction that we saw around that like two-month period of disruption. So there was a couple-month period where funding was just cut and [00:27:00] went offline, and so there was this immediate kind of centralization of programming.
But even after funding came back on, I was surprised to hear just how much programs are planning for and anticipating major cuts in September and the work that they're doing to prepare for that to avoid kind of being caught off-guard again.
So, in one health center we had heard that they had actually stopped enrolling new patients in pre-exposure prophylaxis programming because they're anticipating not having enough viral load testers.
We heard in a few different health centers that they're training up Ministry of Health staff to be able to deliver programming that previously was funded via PEPFAR and implemented via partner organizations that were not directly integrated with the ministry.
We've seen in the news these stories about 50% cuts, and that's all the information that we have. And that's actually all the information they have too. So they are up to the ministry, it sounds like, taking that at face value and saying, okay, there are gonna be 50% cuts. How are we gonna deal with that? And just, I guess, the total [00:28:00] lack of any information in the environment was kinda shocking, and we got to see how difficult it was to plan in that environment.
And just generally, I guess one takeaway is that implementing this kind of programming is really hard. There's this like jigsaw puzzle of implementers, there's lots of dependencies, there's lots of different activities going on, and so being able to be nimble in the face of these changes is really difficult.
Julie Faller: Yeah, and I think the point that you're making about the dependencies across programming resonates with something I've been thinking about, which is just how difficult this environment is to make a living in and also, therefore, how difficult it is to implement programs that are geared at improving people's livelihoods.
And so, in our visits we were talking to people and just one example, we saw a program where they intended to make a bakery and had purchased an electric oven for this bakery, after getting assurances from the national utility that their location was going to be connected to the grid. But that connection never happened, and they waited for a year and ended up having to purchase charcoal ovens [00:29:00] instead because they couldn't use their electric oven.
And another thing that just kept coming up with people was the challenge of inflation. In Malawi, there's been like ongoing and persistent inflation, and that means that it's really difficult to plan, it's really difficult to budget, and inputs that you need just get more expensive than you expect.
Steven Profaizer: I'll add that it was really an honor to get to spend time with some of these communities. They really welcomed us in and gave us a lot of their time as we got a chance to sit down with many of the community members who had benefited from some of these programs. You know, and they spoke very emphatically about the impact that they'd had on their lives. And they shared some of the improvements that they'd been able to make.
For instance, in one village where they had recently received unconditional cash transfers, we heard from a lot of people about the difference that it made to their lives. To switch from a thatched roof that they had to replace on a regular basis and that leaked during the rainy season to a metal roof that was something that would last for much longer and make sure that they stayed [00:30:00] dry.
I found it really moving to hear about the impact those changes had on the community, and I also recognize that from my outside perspective, their overall circumstances largely look the same. To me, that spoke both to the power that we all have to meaningfully help people through effective programs and to how that impact doesn't always look like the dramatic transformation that we might imagine.
Julie Faller: And can I just say one other thing that I've been pondering a lot since we got back is just the value and importance of digging deeper when it comes to thinking about how to interpret information about how programs are functioning. I think we often are looking at data where, this is the survey result, or this is an academic paper that has processed a bunch of interviews and then says what they're about, and it's easy to treat that as cleaner than it probably is.
And so there are just all of these examples where we would be talking to people and they give you some figures. You're like, oh, that's interesting, tell me more. And as you dig deeper, it turns out that actually there was a distribution of prices. And I don't think that’s indicative of intentional misreporting as much [00:31:00] as it is that the world is complicated. People try to speak and communicate in sort of headline terms with each other.
Elie Hassenfeld: Yeah, a similar story or similar example that we heard is we were told that in Malawi, women come to give birth in a facility a month before they're due. And this is intended to enable people to have time to travel before, you know, well in advance of their due date so that they're very likely to be in the facility at the time they need to be there.
And I guess at first, this was reported to us as, "this is what people do." And it was only through additional questioning in various places that we learned, it's not that this is what people do, but this is what the official guidance is. And in fact, when people come, they do come early, they have long distances to travel, but it's more like several days rather than several weeks.
And you know, that's another example of the need to go deeper and really like all of this trip, when I look back on it, people sometimes ask me, what did you learn? Or what did you change your mind about having done this trip, and how is it different from what you thought before?
And often these trips are not trips that lead us to reach new [00:32:00] conclusions, but they do help us raise additional questions that we otherwise might not have asked, if not for having seen things up close in a more concrete way, whether that's about the aid cuts, about livelihoods, about the difficulty of increasing people's incomes, or in questioning the answers we're getting.
And in that way, I think this trip and trips like this are very valuable to us because they help us learn more about things we should be questioning that we might not otherwise be.