13 December 2014

On the Road

Early morning, and I’m sitting on the patio at Dedza Pottery Lodge, staring at a cluster of thick gray-white clouds hovering motionlessly over the mountain just south of us. In the chill of morning, it looks almost like an alpine scene, wintry, even though it’s January in Malawi.

I’m here with my colleague Katharine, a spunky 29-year-old blond from London, to assess a health program funded by the governments of Germany and Norway. Malawi is one of the poorest countries in the world; nearly three-quarters of Malawians live on less than $1.25 a day, in one of those statistics that is impossible to absorb. We’ve been driving through the countryside for a couple of days now, interviewing staff at hospitals and health centers during the day, and typing up and analyzing our notes late into the night.

The mornings are quiet. Below the veranda is a well-tended garden full of flowers—bright reds and yellows, pale pink roses. A gardener in blue coveralls is pushing a wheelbarrow across the lawn, and at the next table, a father and son on holiday are discussing their plans for the day, while Katharine reads Bridget Jones on her kindle and sips some tea.

I woke up this morning out of a strange dream. Blurry images of my childhood; family in a dark, slanted landscape. Couldn’t remember what the dream was about exactly, but I could feel the images inside me when I woke, crawling around like spiders.

Summoned by Johanne, our driver, we pack up our computers, water bottles and cans of Pringles, and load into our Toyota Hilux. Twambilire, our colleague from the Ministry of Health, is already in the back seat, checking messages on her phone. We pick up Mabvuto, another colleague, and we’re off, heading southwest to Katsekera.


The road to Katsekera is steep and muddy because of the rains. It serves as an international border—on one side of the road is Mozambique and on the other, Malawi, and people cross lazily back and forth, over the invisible line in the grass.

On either side, the land is lush and green, stretching out like a massive yawn punctuated by granite mountains that rise up out of no where, like waves cresting.

Pass by people on the road, some strolling, others striding hastily with purpose. There are women with babies on their backs, men in suits, young guys in jeans and shades, others carrying hoes over their shoulders and umbrellas.

Each of us has an allotted place in the car. Katharine sits in the back between Twambilire and I. She’s is as full of energy and humor as a parade, firing off questions, singing along to the music. Twambilire, a 50-something mother of four girls and veteran nurse-midwife, is as cool as jazz; she wears pretty red suits as if they were a second skin, putting me, in my hippie skirts, to shame.

Mabvuto, the chief, as we call him, a big bear of a man in his thirties, sits in the front with Johanne. Mabvuto is the comedian of the team; each morning, he tells jokes. Today, the joke is on Johanne, a self-described evangelist with serious eyes who is in the middle of a month-long fast, which Mabvuto and Twambi find ridiculous. They goad him, say they would never give up food for God. And why would God want that anyway?
Johanne is unmoved, his eyes fixed on the road.

—To cast out demons, Jesus said we should fast and pray, he says evenly.

Mabvuto smiles and looks out the window, Twambilire returns to her phone. After a while, the car gets stuffy and humid, so Johanne cracks the windows, letting in a rush of cool, wet air that smells of wood smoke and the sweetness of the grass outside.


There was debate for several weeks among the team—four based in Lilongwe, an expert in Berlin, two in London, and me in Washington, DC—about what to call our exercise: an assessment, evaluation, a study? Some members of the team wanted to emphasize the non-scientific-ness of the assessment/evaluation/study, and were thus keen to avoid words like “evaluation” because of their (superior?) connotations of precision and generalizability. In the end, we agreed on: “Rapid Qualitative Assessment”.

We developed a conceptual framework and an interview guide, which were reviewed and revised a half a dozen times. Informants and facilities were carefully selected (convenience sample) for Focus Group Discussions. There were meetings and phone calls.

The words we use to describe what we are doing suggest science and precision.

Real life is another matter.


Pull up to the health center 20 minutes late. Get out of the car slowly, groggy from the sedation of the road. There are dozens of women waiting on cement benches outside, many with babies in their laps. The babies’ cries and coos bounce off the cement walls with the buzz of flies and occasional chirp of the bats hanging in the eaves above. Inside it smells of chlorine mixed with the sharp, sour smell of bodies. 

Mr. Kathyoka, the facility in-charge, shakes our hands and leads us to his office. I try my best with a Chichewa greeting, which he pretends is endearing. Mr. Kathyoka is middle aged and wears worn trousers and a button down shirt with the sleeves rolled up. His office is spare—a small metal desk; a couple of wooden chairs; some files piled on a bookshelf. A single window. Lights are off because, like most health centers, there is no electricity.

It takes a couple of minutes for his head nurse and a midwife to arrive. Guilt, because we know that, just like the dozens of other visitors they receive each month from other programs and projects, we are taking them away from patients who have come from God knows how far.

We sit in a circle. Mr. Kathyoka's health center has done well in our program—I have the data in a folder—and we want to understand why. We have notepads on our laps and pens in our hands. The interview guide is there.

We look at each other expectantly. Like at church just before the preacher utters her first word—everyone is locked in, waiting.

—Thank you so much for having us, I start. Tell me about the program.

A pause. It is a good program, Mr. Kathyoka says. It improves services and lives. It helps us see our mistakes.


—And the nurses and midwives, what do your colleagues think?


—They think it is good.

How quickly our questions seem in the wrong order, too direct and impersonal. Outside I hear some boys kicking a ball around; someone sweeping a broom against the cement floor; a radio playing music.

Eventually we coax them into telling us about some of their worries and frustrations about the program. They tell us about missing the deadline to deliver the required reporting information to the district office because of the rains; of district managers who say they will come to visit but rarely do; of quibbles among staff about money; about rumors of witchcraft among villagers suspicious of the program; of broken equipment and delays in getting needed supplies and medicines; of a woman who died in labor on the side of the road.

When we get up to leave two hours later, it is unclear what has been revealed and what has perhaps been concealed. A donor program worth millions of dollars, that brings money and equipment and recognition. Strangers from abroad, passing through for a few hours, people they will never see again, who know and see so little.
The art of interviews is more difficult than is generally assumed.

Towards the end of our interview, when everyone was weary and ready for lunch, I asked if they had any questions for us. There was a pause, then a nurse spoke up.

In a deep, intransigent voice she said: Many other international programs come and go. Will this one stay?

Another pause.


Sometimes, when you’re on the road, looking out the window, you catch someone’s eye by mistake. I don’t like to make eye contact, unless the person is already smiling and waving, because then I feel like a voyeur: watching someone from behind a glass plate, zooming by at 50 miles an hour, a swoosh of air and we’re gone. 

But sometimes you catch someone’s eye, maybe a child who looks scared, about to cry. Sometimes it’s a woman at a vegetable stand with a meek smile, tomatoes piled up in pyramids. Sometimes, it’s a teenager who makes a hip hop dance move, beckoning you to watch, then looks at you with defiance when you turn your head. Sometimes, the face is just blank, or at least it seems blank, impossible to read. A little hard maybe, unamused. 

Sometimes, when I look at peoples’ faces, what I’m really thinking about is my own face—sweaty, didn’t put makeup on today, bad night’s sleep, stomach a bit off, those strange dreams.

My colleagues are talking in Chichewa in the car, laughing. I wish I knew what they were saying. Invisible walls all around. 


We're going to Phimbi health center today. It's a two-hour drive north in the hills, up from Balaka Central Hospital. 

It’s rainy and warm and we have to crawl slowly over roads marked by deep muddy canyons. I'm in the middle seat today, and each time Johanne inches ahead my shoulders and legs knock against Twambi and Katharine.

We arrive late and begin the familiar recital: walk up slowly, over a gravel driveway that crunches beneath our feet. Stares of mothers waiting. The in-charge standing by, anticipating our arrival. Shake hands. Sit down. 

We're ready to begin, pens in hand, expectant faces. One more look at the interview guide, which is dirty and wrinkled, and I start in with some words of thanks for their taking the time to meet with us. 

Then it starts to rain. Not a light, gentle shower, but heavy, relentless columns that pound down against the corrugated iron rooftop like bullets.

The noise is so loud that we can’t hear anything else, not even each other. So we, all of us -- the health workers, the facility in-charge, our little team from Lilongwe -- just stare out at the rain, hands folded in our laps, not saying a word.   

19 March 2014

At the Airport

I was waiting at the gate at Johannesburg’s O.R. Tambo international airport, computer in my lap, pleased that I’d found a place to sit close to the check-in desk, where there was already a small group of people hovering anxiously next to the sign for priority boarding.

I’d been comfortably seated there 30 minutes earlier, when they called us up for a special security check—something they were doing for all the flights headed to the United States.

—For fuck’s sake, I’d muttered under my breath, agitated as usual just by being in an airport. I hate flying. Even the smallest bump or a noise I don’t recognize sends my imagination whirling, and the thought of sitting for 15 hours, hurtling over the ocean in a steel tube in the dark, had been on my mind for days.

I closed my laptop, gathered my notebook and pen, and rushed to join the line, which formed instantaneous, stretching down the terminal’s long white corridor.

I wound up in the middle of a group of 20-somethings who were returning to the States from vacation. In hip, studied outfits of trendy sunglasses and high tops, they talked loudly, conspicuously, surrounded by bags of alcohol from duty free. I listened to the girls tease one of the guys: we know you’re excited for the security pat down, haha. Evidently, it was the most action he’d had in a while.

Further up in line was a tall American who looked to be in his late twenties, and wore a khaki vest with an inordinate amount of pockets and zippers, all of which were stuffed full of God knows what. He had a scraggly goatee and eager blue eyes, and he gazed into the crowd, as friendly and good-natured as a pine tree.

There was an older American couple, also in hiking gear, who smiled vaguely at the group of cool cats talking behind me and looked mildly stoned. An attractive older couple, dressed in understated, expensive clothes, were at the head of the line. They kept their arms crossed and stayed close to each other, as if to avoid being contaminated by the masses. Next to them were three middle-aged ladies, one of whom wore an enormous pink blazer and kept laughing like a hyena and pointing at her phone.

There was a group of young women in scrubs; some quiet loners like me; businessmen; a of couple families with kids.

The security check was relatively painless and I made it back to my original seat. Fired up my computer. Exchanged polite smiles with the lady sitting next to me. Checked the time.

Then one of the SAA employees ran down the aisle behind me yelling for help.

I turned my head and noticed a man, about 20 feet from where I was sitting, slumped over in his chair.

He must not be feeling well, I thought. The commotion died down after a few seconds, and I looked again at my computer.

But then, a minute later, a strange sound wafted through the crowd, low and anguished, like a drone, and when I looked back down the aisle, I realized that the sound was coming from the man. Except now he wasn’t slumped over in his seat—now he was lying on the floor, and the girls in scrubs were on their knees, pounding on his chest, breathing into his mouth, while SAA employees ran frantically back and forth down the aisle, making telephone calls and talking in urgent, hushed voices.

And what started to dawn on everyone who was watching was that this man was either dying or already dead.


It’s hard to believe—that someone can be here one minute and gone the next, in the middle of a crowd, beneath the fluorescent lights, next to the Nandos.

What you expect, somehow, in a moment like that, is for everything to stop. You expect the crowd to be silent, for all conversations to cease, for all attention to be focused on that man, who ever he was, at least for a little while.

But what was so strange was that things did not stop. Some people gathered around him, of course. A couple of the 20-somethings who had annoyed me so much were crying silently in their chairs. Some, like me, watched from our seats, glancing at each other expectantly, waiting.

But all around us, things went on. People floated by on the moving walkway that snaked past our gate, bags on their shoulder, mostly unaware of what was happening. A voice came over the loudspeaker to make the final boarding announcement for a flight to London.

Even among our group at the gate, many seemed not to notice what was happening. The pine tree guy, who was sitting a few seats away, chatted jovially about organic farming and Al Gore with the two American campers he’d made friends with in the security line. They never once turned their heads or stopped talking.

The three women on vacation, who were in a better line of sight than I was to see what was happening, took selfies on their phones and laughed, only pausing after about 15 minutes had gone by.

The expensive couple stayed close to the check-in desk, jealously guarding their first place at priority boarding. They glanced over their shoulders once or twice to see what was happening, before turning their backs and checking their watches.  

I wanted to tell them to stop, for God’s sake, stop. Can’t you see this man is dying? He’s dying, right there in front of you.

Can’t you see?

What’s wrong with you? It’s impossible. This can’t be real.


It’s easy to moralize about a scene like this. But hang on, not too fast. We've all done things that don't make sense, behaved in ways we know we ought not to have behaved, for reasons we scarcely understand.  

So then maybe this is an example of our collective numbness, an example of how easily distracted and self-involved we can be. Those ladies taking selfiesthey represent all of us, don't they? Taking pictures of ourselves while tragedy unfolds around us? 

Or perhaps we can see it as a metaphor for impermanence, and the need to live life to the fullest, because you never know what day is your last.

Yes maybe. Both things are true, of course. We have a huge capacity for compassion, but sometimes we are as unmoved as stone by other peoples' pain.  

And most of us live as if we had all the time in the world when the truth is, we do not.

Life is precious, as Frederick Buechner writes, and “We must be careful with our lives, for Christ's sake, because it would seem that they are the only lives we are going to have in this puzzling and perilous world, and so they are very precious and what we do with them matters enormously.”

Everyone knows this. We don’t need to be reminded.

Except that we do need to be reminded, all the time, at least I do. Because no matter how much I know these things, intellectually, it is another matter entirely to live as if they were true.

Maybe that’s why we have religious rituals like Lent, which began just a few weeks ago. You don’t have to be a church-type to appreciate the idea—of taking time out of our frenetic, 100mph, too organized, too business-like lives, to stop and take stock, to step back and try, again, to get ahold of who we are and where we are going. 

Yes, these lessons are important. 

But still. 

There's a part of me that doesn't want to draw out lessons about Mankind from that night in Johannesburg, no matter how true they might be.  

Because it wasn't mankindbut one manwho died that night. One man who had a story of his own, who is more than the ideas we may draw. One man in the crowd who was someone. 

I tried to fight them, but tears welled up in my eyes, and so I sat at the gate and cried silently for a minute or two.

I cried because the man had been alive a minute ago but now he was dead, and it is sad when people die. I cried at the heroic effort that was being made to bring him back to life, how hard they were trying, and how right they were to drop everything and get down on their hands and knees and fight to save him.

I cried at the people around me who were carrying on, and I cried because I knew that I too would get up a few minutes later when they announced that our flight was boarding, and would become impatient and worried again, about the flight, about there being enough room in the overhead compartment, and I would feel sadness and exasperation at myself for how petty I can be.

They called us to board, and so we left him there on the floor, only to learn later that he had in fact died, despite the best efforts of his fellow passengers to resuscitate him. 

I wish that, before we boarded, we had stopped what we were doingall of us, together, strangers, but not strangersand been present with him, to honor his life and the fact that we were a part of it for a short time.


No man is an island entire of itself; every man  is a piece of the continent, a part of the main;  if a clod be washed away by the sea, Europe  is the less, as well as if a promontory were, as  well as any manner of thy friends or of thine  own were; any man's death diminishes me,  because I am involved in mankind.  And therefore never send to know for whom  the bell tolls; it tolls for thee.

--John Donne

28 June 2011

Evening Shadows (Dispatches from Kabul)

On Saturday afternoon, June 18, a group of young men approached the entrance to the Kabul central police station and proceeded to detonate a bomb attached to one of their vests while the others opened fire at whomever happened to be standing around. Nine people were killed.

When I heard about the attack, I did a mental calculation as to the last time I had passed by the police station, and when I might have passed by again.

It happened midday, about 1:30 p.m. The time when lunch is settling in your stomach. You run out for an errand, maybe, or make a phone call, squint your eyes at some emails you need to return—while somewhere else in the city people are dying.


I had come to Kabul two weeks earlier. Caught the mid-morning flight from Dubai. Ascend, up and up, over a skyline thick with high rises, sharp glass and steel that cut into the humid, polluted air like a forest of dead trees.

A few hours later we descend into Kabul. Flew in low, or at least it felt low, skimming the tips of the Hindukush mountains, which surround the city like a massive fortress.

Those mountains—staggering, raw. As imposing as thunder.

The plane bumped and jolted in the wind. Felt like we might be tossed down into those peaks, like we could be swallowed up and disappear.


I was in Kabul to support the Health Economics and Financing Directorate (HEFD) of the Ministry of Public Health as they evaluate a conditional cash transfer program that was recently piloted. The scheme gave cash to mothers conditional on them giving birth in facilities and having their children fully immunized with DPT3. The program also provided incentives to the community health workers who are supposed to encourage and help them.

As part of my assignment at HEFD, I conduct key informant interviews with health policy and program experts. They tell me about their projects—We train midwives. We create guidelines. We build capacity.

They whisper about the latest controversies, like the survey that shows a maternal mortality ratio (MMR) much lower than the one calculated in 2006—which showed an MMR of 1,600/100,000, the highest in the world. Some don’t believe the numbers. Others are worried what they will do to funding.

Informants complain about other programs, about being left out of conversations and meetings. Once I gain their trust, they lean in, keen to tell me, the rooky, what their business is really like. Their comments about their Afghan colleagues are full of admiration and distrust:

—They are great at extraction, one says. They’ve seen a lot of people like us come through.

—They’ve learned how to survive, says another.

Everyone is very helpful and misleading.


It is Friday, the Holy Day. Early morning and the compound is empty, the sky gray.

The night before, I was awoken at 3 a.m. by a tremor. Kabul is near the meeting of the Indian and south Eurasian plates and there are frequent rumblings. Suddenly awake, alert, I strain my eyes to see the ceiling, the outline of the door. I imagine the walls caving in, crumbling to pieces.

Now on the road, I’m unsure where to go. Look out the window, men and women snaking between cars on their way somewhere. Everything about them is long and elegant: long beards, long drapes of white, taupe, gray, billowy blue chadaries. My own head scarf keeps falling clumsily to my shoulders.

My driver leans heavily against the steering wheel, while the shooter in the front seat, an AK47 draped lazily between his legs, picks at his teeth. We pass by a mosque, a market, crooked back roads that lead to the foothills beyond.

The police station is on our right, the same one I will pass twice a day for the next two weeks, the same one that will be attacked a few days after I leave. I hardly notice it, though. I’m looking in the opposite direction, at a wall peppered with graffiti. Something is scrolled in blue paint in Dari next to images of birds, one after the other—wings open, flying.

I ask the driver what it means, but he doesn’t speak English well and hesitates.

Then: It means we want a better life. It means everybody should have a happy life.

I think: Of course. It means Peace.


The pub on the U.S. Embassy compound is called the Duck and Cover.

Meet some friends there one night, two young American guys working on civilian-military relations for General Petraeus. Over beer, I tell them about the incentive program whose evaluation I’ve come to support. They tell me about another incentive program, this one to empower (read: arm) local police forces, also called militias.

Despite the fact that Karzai is a Pashtun, there are many who see him and all the other vestiges of security, as illegitimate, a mere reconfiguration of domestic power structures to serve external interests.

The Afghan National Auxiliary Police and the Afghan Public Protection Program are meant to protect the people who are on the right side of the war. My friends at the U.S. Embassy believe in the program. It’s not perfect, they say, but it’s a good thing to do.

—But I thought we are trying to disarm people?

—Well yeah, one of them says, we arm the locals so they can protect themselves from the enemy.

How can you tell which is which?


There is a restaurant called Cedars House near the central business district. My colleagues and I sit outside, in the garden.

There are so many gardens in Kabul. Sprawling, with trim lawns, lined with pink and red roses.

The evening is cool. There is a quiet murmur all around us: the chink of glass, conversation in the moonlight. Our meal is slow and meandering, the conversation drifting like smoke.

My Ministry colleagues tell stories. Their days at university in California, St. Louis, the Netherlands, Liverpool. They talk about cricket on the weekends, homes full of relatives, their crowded lives. They poke fun of each other, tell jokes, talk fluidly about philosophy, poetry, literature.

Shards of their pasts are occasionally exposed. One’s boyhood as a refugee in Pakistan. The dark days of the Taliban when they all grew long beards.

I study them. It’s like trying to keep my eye on a flame. I want to understand their lives, but I’m on the outside, straining to look in.


They say some expats can’t leave warzones. They get stuck in the netherworld of expat life—behind walls, lonely but never really alone. Submerged in motion, in alcohol, some of them, in constant work. Wake up one morning and realize the only place they feel comfortable is in places where they are uncomfortable.

A storm passes through one afternoon. I’m standing underneath an overhang at the security office with Beth, a British security specialist. She’s open and friendly—shakes my hand, offers me a cigarette as we watch the rain.

She was in Iraq for a while, passed through Sudan, then Kabul.

—I tried to be normal for a year, she laughs. She moved to South Carolina, started a business. “It didn’t work.”

Later, back at the Duck and Cover, I watch her compatriots at the bar: older men with tanned, deeply lined faces, and tattoos on their arms. One wears a gold crucifix, which hangs down over a t-shirt emblazoned with expletives.

It’s karaoke night, and one of them gathers himself solemnly at the mic. A hush falls over the room while he sings:

Would you know my name… If I saw you in Heaven?


There’s a lake just outside the city. Some colleagues and I have lunch—Karayee (lamb with tomatoes and garlic), cucumbers, flatbread and yogurt—while lounging on Afghan rugs. We’re in an open-air bungalow of sorts, on stilts that juts out over a cliff above the lake.

It's a rare midday break from the office, and for a while we are all quiet together, looking out over the water, which changes color in the pale afternoon sunlight, from turquoise to shades of grayish blue.

They are like ship captains, these men: smart, realistic, ambitious, trying to navigate the choppy waters of politics and money and ego that are the stuff of the aid business.

There are something like 62 donors to Afghanistan. Six provide more than 90 percent of external support. Aid flows amount to more than 50 percent of Afghanistan’s gross domestic product: official ODA from OECD members rose from US$87 million in 2000 to US$2.2 billion in 2005. [1]

The United States is by far the largest donor. Since 2001, the U.S. has appropriated US$127 billion for the war, and the U.S. military is currently spending nearly US$100 million per day in the country, a total of around US$36 billion per year.

The question on everyone’s mind is Sustainability. It’s the first thing informants ask when I mention the HEFD program to help save mothers’ lives. How will the Afghans, how will any of us, they ask, make this last?

One afternoon, I meet an American official who sneers at the money being “dumped” into Afghanistan. What about the taxpayers at home, she says? Too much money is never enough!

But the amount of aid that ends up in government coffers is hugely reduced by the fact that an estimated 40 percent of all aid goes back to donor countries in corporate profits and consultancy salaries (like mine, with my health insurance and pension, benefits some of my Afghan colleagues do not receive)—a total of some US$6 billion since 2001.

Later, I ask an Afghan colleague about the American official I met. He smiles thinly and looks out the window of our car.

—She has a lot of power, he says.

I think I see a flash of disgust in his eyes.


It’s early evening. A friend and I go up to the roof of the guesthouse where I stay, pull some concrete blocks together and sit down, look out over the city.

Sounds now familiar of the city at dusk: Early evening traffic jam. Some men gathered on the side of the road talking. A stray dog barking down a dirt alleyway. Beyond, the mountains stare back at us, harsh, haunting, somewhat obscured in the shadows of the setting sun.

Then the wind picks up, blowing dust and sand in our eyes. Feels like little needles against my skin.

A few days later, my friend will skype me to tell me about the attack.

I will ask him with a kind of panic if he is okay. How did it happen? Were you afraid?

And what will it take for these things to end?

—I wish I had an answer, he will say.

[1] See: Who Owns the Peace? Aid, Reconstruction and Development in Afghanistan, Jonathan Goodhand and Mark Sedra.