Africa | Mark Michaelis' Weblog

GiveDirectly Impact – Questions and Impressions Following Rwanda 2022 Visit

April 27, 2022

My initial attraction to GiveDirectly, and why IntelliTect decided to support them last year, was the studies they did at the onset to show the positive impact of the cash transfers and verification that, in fact, recipients overwhelmingly made positive choices in what to do with the money. Rather than drinking, drugs, or gambling, the recipients chose to purchase a cow, roof, health insurance, a child’s education, home improvements, or something equally worthwhile. Overwhelmingly, the recipients net worth and quality of life improved significantly. During my visit this tip, it was a blessing to be able to see their gratitude, excitement, and accept their thank-yous. While I only visited four or five households this week, I came away with a strong confirmation that these recipients were exceedingly grateful for the cash transfers and that they were not making unhealthy choices about how to spend the funds. In fact, in the Miller, their choice was especially strategic (at least in terms of income generation).

The GiveDirectly team I met with is relatively young and eager about the mission of GD. Everyone had a college/university degree (the academic discipline of the degree didn’t really matter to GD which makes sense to me). Furthermore, based on the team I interacted with, they were all good hires – meaning the GD employees were hard working, believed in the mission, were thoughtful, and eager to improve. In Rwanda, like Uganda, having a degree doesn’t guarantee you a good job, so GD gets to choose the best applicants. (That said, Rwandan unemployment figures are extremely low – less than 2% – which seems very suspicious.)

Two question areas remain, however, and I’m grateful for the ongoing discussion with GiveDirectly as they help me to resolve them:

Is income improved over time and by how much?
GD’s goal is that people would escape extreme poverty. However, remarkably, they don’t have any data/studies to show this is, in fact, achieved. I’m very surprised by this given my initial evaluation of them at the onset of IntelliTect’s donations was that they were data and research driven. As a result, the following questions arise:

After five years (for example) have recipient households escaped out of extreme poverty? GiveDirectly doesn’t have any data to say that they do.
What is the percentage of increased income?
One study in Uganda, which GD provided for me, shows that over twelve years income goes up a total of 17% (I assume this is after inflation as inflation alone in that time period would be more than 25%). A recipient who started at 1 USD/day would, therefore, be earning less than 1.20/day after 12 years. Another study in Kenya concluded that, “At four years, the families that received GiveDirectly’s cash were not meaningfully better off than control families.”
- What is a family’s income to start? (Seemingly, GD was not gathering this information in their census – at least for the one I participated in?)
- What is a family’s income after five years (and more)?

Why had GD not been measuring income improvement both before and at a significant amount of time after, in fact why wasn’t it one of their main measures? One obvious reason for not measuring a long time afterwards would be cost, but surely this is the very purpose of the donations and, therefore, you should verify it is working in the long term – even given the expense. At a minimum, use Rwandan government provided data and verify it with sampling.
The other organizations I met with during my East Africa visit learned that training in personal financial, gender sensitization, marital conflict (especially when money become available), and income generation were critical to escaping poverty. What was GD doing such that this training wasn’t needed and how did they verify it?
I have no doubt that net worth and quality of life improved with cash transfers (even perhaps after five years though I haven’t looked for the research to support this). How do you measure effectiveness of poverty alleviation when considering increased income versus net worth & quality of life improvements?

Why is GiveDirectly’s detection of household conflict 10% of the Rwandan wide figures of domestic GBV in the last 12 months?

Why was GD’s detection on conflict across their clients (~2%) so vastly different from UN Women’s (at the time of this writing, 20% experiencing GBV over the 12 months)?
How much was the emphasis to not have conflict presented during the community meeting skewing their ability to detect the conflict?
Surely GBV was included in what GD considered conflict or, was it not a significant factor in determining who should receive cash transfers? If not, why not?
If GBV was not conflict enough to disqualify a household from receiving a cash transfer, what conflicts were significant to disqualify them (however rarely)?

Why does GiveDirectly’s overhead reporting differ from GiveWell’s evaluation on them?

GiveDirectly claims their “overhead” is less than 10% and yet GiveWell’s evaluation (and by the way, GiveWell rates them extremely well as an organization) shows their overhead as 17%?

GiveDirectly’s response to my email on this topic stated (and is consistent with their website):

The discrepancy boils down to a difference in calculation. We calculate efficiency as Cash transfers ÷ [Cash transfers + cost of delivery] which historically comes to ~90%. GiveWell calculates it as “Cash grants make up 83.0% of GiveDirectly’s all-time incurred expenses.” The difference is that we break out our measures into two distinct business systems, (1) cash transfers and (2) fundraising to deliver as cash, with a core performance metric for each; whereas GiveWell groups them all together.

I’m concerned about this for multiple reasons.

The most significant is that they receive money that is restricted to a specific expense category (namely fundraising) rather than the generally preferably unrestricted donation. And, as such, they credit the donations from you or me as going directly to the recipient (well, except for transferring the money). In other words, while generally restricted funds are less preferable, because GiveDirectly has restricted funds for fundraising and they are crediting themselves as having a lower overhead for your or my donations than everyone else even though, in fact, their fundraising is nothing special, it is just that the unrestricted funds that you or I are donating, are not going towards fundraising (or perhaps even overhead).
GiveDirectly’s fundraising may not be particularly good but they are playing by different rules so, on their website, they look better than other organizations website shows the fundraising as a normal cost. This seems suspiciously disingenuous – and hard to decipher – and outside the spirit of truth in reporting. Help me understand?

Questions:

When, on their website, GiveDirectly doesn’t include their fundraising costs in the measure of giving efficiency and yet compares themselves to other organizations, are they subtracting the fundraising costs from other organizations metrics?
Where does overhead, such as the cost of management cost or accounting, fit in their spending report?
What makes GiveDirectly special such that they believe that not reporting the cost of fundraising the same as everyone else is acceptable? Is it simply that they have a donation restricted to fundraising? What if everyone did the same, would we end up with more truth or less?

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Visiting GiveDirectly’s Recipients (East Africa Day 12: 2022-04-25)

April 25, 2022

Tonight we fly home, Kigali->Entebbe->Amsterdam->Seattle->Spokane. A total of around 30 hours. Before that, however, we get to go meet with some of the specific households that IntelliTect supported with their donations to GiveDirectly(GD) in 2021. It’s about a 4-hour drive to the village of Gitwa, and we will only be able to stay about an hour before heading back, but none the less, it provides an opportunity to hear first hand about the impact.

Upon arriving in Gitwa, we first went to the government village officers where we met with the section head. He had one of his staff present the impact on the community, using PowerPoint and a projector, comparing before and afterwards.

The impact included:

100 percent of the households had purchased government health insurance (no doubt a government encouraged purchase)
100 percent of the households had electricity – supporting a minimum power equivalent to three lightbulbs
The vast majority owned a cow (another strongly government encouraged purchase)
<more data to come>

After the presentation we got to wonder around the community and I was asked to select any household I would like to visit. Note, as your read these description, they are each anecdotes. They can’t be used to measure overall success of the GD program. None the less, I was encouraged, blessed even, by the interactions.

The Miller – Mugabe Moise

The first building we came to was a flour mill and the owner, Mugabe Moise, was outside. Prior to GD he was renting flour mill equipment and leveraging some training he had attended. Using the cash transfer, he purchase the flour mill equipment, and a second one, outright. He was paying ~5 USD/day for the electricity to run the mill and about 15 USD/month for maintenance. In addition, he seemingly employed one person to run the mills. As a result, he calculated his net profit at the equivalent of 5 USD/day, significantly higher than the 1.90 USD/day ppp value set as the extreme poverty delineator. (Although, I confess I didn’t find how many, if any others, in his household he was supporting.) This was clearly a success story. I suspect he was very likely already above or trending above the poverty line even before the GD money, but regardless, it was a huge success and I’m excited about what the future holds for this gentleman.

The Excited Widow – Musabyimana

This woman, Musabyimana, was so excited she invited us into her home. In the corner was a small wooden bench standing on it side. She explained that before receiving the money, that was the only furniture she had. Now, she had this wonderful set, and the bicycle. She also had a cow and an additional room she had added on for where to put her next cow.

The Farmers – Everist Niyonzima, his wife Uwanyirigira Anne Marie, and their grandchild

This family, Everist Niyonzima, his wife Uwanyirigira Anne Marie, and their grand daughter had peas that were drying on a cloth outside. They said they were for themselves but if they every had excess produce, they would sell it. It didn’t seem like they had any steady source of income and they were seemingly living off of subsistence farming. Their grand daughter lived with them as she was a surprise and so this couple was helping out their daughter.

One of the things they purchased with the cash transfer was a new corrugated iron roof. While they were incredibly grateful for the money, it was hard to gather what they had spent it on and the impact it had made.

(When we asked to take a picture the Everist asked if he could please go get changed first as he wasn’t expecting visitors.)

We met a few more folks during our hour long walk. Some of them invited us into their home. All of them were extremely grateful. None of the remaining ones provided a clear indication that they had used the money to establish a stable income. All of them expressed joy at their improved quality of life due to the various spending that included:

Furniture
TV and speaker
Land for their children
Improved stucco walls
Painted their houses
A cow
Additional rooms

On the way back to the car, however, we met two folks that were working to establish a business:

Leveraged the cash for establishing a mobile banking stall within the community
Bought a cow and sold it at double in the town (15-30 minutes from the village), with the intent to purchase more cows from the community that he could sell

Following my visit, I took some time to write up my impressions and questions regarding GiveDirectly. In summary, I can say with confidence that it was a blessing to be able to see their gratitude, excitement, and accept their thank-yous.

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Introducing GiveDirectly (East Africa Day 8: 2022-04-21)

April 21, 2022

Traveling Summary: Driving 6h 49 m driving 189 km

After reaching the GiveDirectly office in Ngororero, we switched to their hired car and drove out to the district government offices. We met with the district government leader to confirm permission to go into the community. From then we headed up into the mountains, split up, (Phil and Sean going with their own GiveDirectly field worker), and then want to observe our first census.

Introducing GiveDirectly

“GiveDirectly is a nonprofit that lets donors like you send money directly to the world’s poorest households. We believe people living in poverty deserve the dignity to choose for themselves how best to improve their lives — cash enables that choice.” In Rwanda, where IntelliTect has donated, each recipient was given a little more than 800 USD in two installments a month a part. Interactions with the recipients are as follows:

Community meeting: a section of 2-3 hundred recipients is gathered together and informed about the unconditional cash they are going to receive and how the process works.
A meeting with each household occurs, called a census, where information is gathered to support the process and, if necessary, a phone and SIM card is provided in support of a mobile bank transfer to the recipient.
Recipients are contacted by phone and informed about the cash transfer.
Cash is transferred in two installments separated by a month.
A follow up “audit” occurs in which GD asks recipients how they spent the money.

GiveDirectly Census

The census I observed was led by Priscila and I had my friend Cedric (whom I met earlier) help with the translation. We were accompanied by the chief of the district and two armed police they brought with them. I suggested that armed police might interfere with the census process but I was assured they were for “our protection” and the GD staff acquiesced.

The process went something like this:

Introductions
Explain the program
Confirm that the cash transfer is non-conditional
Caution the household of potential scams
Ask the recipients which of the heads of household would be the official recipient (if no preference is specified, GiveDirectly chooses the female) and get confirmation that both participants agree. About 60-80% of the time the household selects the female and if the couple doesn’t express a preference, GD chooses the female.
Document all income-generating activities – surprisingly, this didn’t record the amount of income, just the various activities (more on this later)
Provide the option for a new Motorola phone (<15 USD value subtracted from the total cash transfer) with instructions on the mobile banking (via which they will receive the cash transfer)
Review guidelines (like no conflict – more on that later) and spending exclusions (which include drugs&alcohol, gambling, and high-interest loans)
Confirm identity and electronically sign acceptance agreement
Photos of both recipients, family, and the house (inside & out)
Goodbyes/thank-yous

Generally, a household census is expected to take around 30 minutes but ours was more like 50 (presumably because of the pesky foreigners that were getting in the home.)

It was a well-run process. In addition to the optional phone, the household was provided with a handout explaining the program and identifying the amount of the cash transfer. The census data was recorded in a mobile-enabled, offline (Salesforce) application which included the recording of all photographs.

Before the census, the recipients didn’t know exactly how much they were going to receive – well except for rumors from the neighbors. The actual transfer would occur in two separate transactions, the first within a month or so and the second a month after that. Regardless, once the amount was confirmed, the joy and excitement of the recipient household was overwhelming. In fact, when we left and passed a second household who Priscila would be taking a census with next, the mom came out and gave me a big hug. As a GD field worker, Priscila’s job was to meet and take a census with 10 households per day, which included the time taken to travel between households.

Community Meeting

By this time we were running late for the community meeting. This was where GD would announce to the next community that like their neighboring community before them, they would be receiving the unconditional cash transfers. As we approached the building — an old auditorium from a private school that had closed due to a lack of paying students — we could sense the excitement. When we walked in everyone was celebrating by singing. The song was a gospel-sounding government song about following the rules and something about security. It was emotional to hear, but upon learning the translation, it seemed eerily like George Orwell’s 1984 — but no one seemed to be aware or have any concern. Interesting!

The community meeting outlined the process, covering much of the same information that was presented in the census (which was next after the meeting for this community). In addition, the district chief presented before and emphasized after, how everyone must follow the rules, watch and report their neighbors for any suspicious behavior, and implied that the GD activity was in some way associated with the government. When GD presented, the fieldworker got the crowd excited with a shout of “Give” to which the audience responded “Directly.” An activity repeated throughout to help keep people’s attention and excitement. The meeting ended with questions, many of which were already answered but there were some areas of clarification.

From my perspective, both GD activities were emotionally charged and the joy and excitement palpable. A few times, especially at the start of the community meeting, I had to suppress my emotional joy bordering on any tears leaking out. I was honored and blessed to be there.

One important point to note: GD highlighted that the key goal of the cash transfers was for these people to escape extreme poverty. As a donor, this was exactly what I would hope. Unfortunately, it actually opened up an important question for me.

What was the increase in income from before the cash transfer to (some significant number like) five years later?

A second question related to the point they emphasized during the community meeting: couples should not have conflict in order to receive the cash transfer. This is important because they want unity in the financial decisions the couple is making. While I (obviously) have no conflict in my marriage :), this raised an eyebrow for me:

Why did the census, which asked about marital conflict, only detect conflict two percent of the time when UN Women had the following statistics at the time of this writing:
- Physical and/or Sexual Intimate Partner Violence in the last 12 months: 20.7%
- Lifetime Physical and/or Sexual Intimate Partner Violence: 37.1%

More on these questions and my GD impressions here.

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Walking the Back Streets of Goma (East Africa Day 8 Morning: 2022-04-21)

April 21, 2022

Before breakfast, and like the previous day, I awoke, worked for a couple of hours, and then joined up with Phil and Sean for a walk. This time, however, we decided to be more deliberate in walking into areas that were less tourist and commercial (but staying within the safety boundaries suggested by the hotel). We headed north along the main road until we found a dark enough alley – and in this case, I’m referring to enough of the black, volcanic dirt for a road rather than something paved. It was great. We were able to interact with the locals by playing pool and soccer, and obtain a sense of what the real Goma is like behind the preponderance of NGO buildings on the main streets. (Sean suggested we play NGO bingo.)

(See more journaling below, but there are lots of photos.)

Our time in DRC was brief and World Relief was careful to keep us in relative safety, avoiding taking us outside of Goma. For example, World Relief even avoided letting us see the volcano, which was only 100 miles away. I quickly accepted this (albeit disappointed). However, this short walk around a poorer neighborhood of Goma was a highlight. It gave us a clearer picture of how the urban population lives than our mostly car-limited view the prior two days. Additionally, part of the walk took us along the DRC-Rwanda border. We could see the stark contrast between Goma, DRC and Gisenyi, Rwanda as we walked along the border, with wood “slum-like” housing on the DRC side and brick structures on the Rwanda side. The “satellite view” between on its own reveals the inequalities.

The satellite contrast between Goma, DRC (left) and Gisenyi, Rwanda (right)

Upon our return to the hotel we packed and grabbed breakfast before checking out and meeting our driver from World Relief. Checking out was somewhat painful as getting each receipt, of three, took nearly 10 minutes and yet when I went to the “payment” room they only charged me for two rooms. I questioned them and they said it was fine. Knowing that they were underbilling, however, I repeated and insisted they had made a mistake. They finally went to check and then wanted to reinvoice while I waited. We were running late so I insisted on paying and letting them figure out the invoicing process after I left.

Our driver took us to the border. Here, we left the car and walked through security with our bags while they scanned the car for misappropriate material. We then went through DRC immigration followed by Rwanda immigration. Since we have a multi-entry East Africa visa we hoped they would just let us in, but no such luck. The multi-entry East Africa visa allows you to pass between Kenya, Rwanda, and Uganda an unlimited number of times, once you leave those three countries, the visa expires – so we had to get a new visa. And, hoping we were going to Burundi (but no East Africa countries) later that week, we opted for the multi-entry Rwanda visa, paying 70 USD rather than 50 USD. Our driver insisted on staying with us until we had completed the immigration process – which took about an hour, but now that we were done, we said good-byes and continued into Rwanda. Unlike on the DRC side, there were not motorcycle scooters (motos) waiting for passengers. However, we walked down the street a ways and found a taxi area. We negotiated the rate and then each boarded a separate moto for a ride back to the car (totaling 4.50 USD and about 10 minutes journey). I was happy that I finally got Phil on some local African transportation, but don’t tell his Cathy it was my choice to use a moto please.

Unfortunately, since we were late, we had to skip our planned swim in Lake Kivu and continue on our way to Ngororero for our meetings with GiveDirectly.

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Visiting Homes in Goma, DRC with World Relief (East Africa Day 8: 2022-04-20)

April 20, 2022

Travel Summary: 5h 5m driving 32.2 km, 47 m walking 3.7 km

Today, I woke early and spent time trying to catch up at work before heading out with Sean and Phil for a morning walk around Goma. At 8 AM, we went to the World Relief Office in Goma and met with the team there.

They reviewed the various programs that World Relief is running. I was impressed. In addition to our visit to the clinic yesterday where World Relief is funding the fistula surgeries, they also have numerous additional programs. Below are some highlights. Notice the broad “wholistic” focus, with programs covering everything from GBV, couples facilitation, to Savings & Loan programs.

Sexual Gender-Based Violence (SGBV) and HIV programs
Helping survivors with:
- Self-confidence
- Overcoming physical obstacles caused by SGBV (such as providing fistula surgery)
- Help with social and spiritual poverty, including helping them know and believe the truth that they are valuable to God and that he can help restore their life
- Process
  - Train church and community leaders on how to care for survivors
  - Establish SGBV/HIV awareness groups
  - Identify survivors
  - Physical rehabilitation
  - Socio-economic reintegration
  - Psychosocial reintegration
  - Spiritual rehabilitation
Community Empowerment Zones
- Work with local church and community leaders to start collaborating on poverty in the region and how they can help.
- Train the trainer education for local and community leaders with World Relief wholistic program curriculum
Agriculture
200 farmers empowered with livestock and agriculture support
Food Security and Livelihood
Providing seed, tools, and technical training for farmers
Peace training to help resolve conflict
Saving for Live
Saving and Loan programs
Trauma Healing
Community Health
Families for Life (FFL)

For dinner the night before I met with the director of the Families for Life program as was impressed with all they are doing and the impact it is making. I confess there are times that I assume that people in extreme poverty are not ready from programs like this. However, I am just wrong. In fact, when you are living under constant stress and you need help navigating complexities, programs like this provide direction and support that can be crucial.

One of the interesting effects of programs like Families for Life (FFL) is that more couples are going to government offices for civil marriages in addition to their church wedding. Why you might ask? Most couples are getting married in churches which the government doesn’t recognize. And, if something happens to your partner, there is no common law marriage which allows assets to be inherited from one partner to the other following death. Thus, the surviving partner can be left with nothing. However, since the FFL program teaches couples the importance of the civil wedding, more and more couples are going through the process and so they are protected.

Intuitively I fully support the various programs that World Relief has and I’m excited about the impact it is making. My one disappointment is that there isn’t any real data that points to the impact. There is no measurement of things like increased income over time (like Capable has). Even if this metric is not relevant to World Relief, are their other metrics they should be measuring? Discussion on the topic this morning didn’t result in any clear changes or identification of metrics that should be pursued, but I’m hoping for follow on discussions after I leave. I’m trying to be careful to not force Western quantitative ideas onto cultures where they don’t work, but I’m also wanting to push the organizations we partner with to excellence and being able to measure the excellence.

Following out morning meeting at World Relief – DRC headquarters, we headed out to a church to meet with local pastors who have been collaborating with World Relief.

It was interesting that prior to World Relief’s initiative, there was very little collaboration between pastors. Furthermore, the church was essentially only focused on their own congregants. After the training, pastors saw the value in collaborating and reaching out to the community. One church had reached out to widows and provided housing for them. It was a blessing to care for them and the widows were blessed by the desperately needed assistance. Another couple had separated because the wife was disrespectful to the husband because he couldn’t find a job. The situation escalated to such an extent that she had moved out. However, through the FFL program, the couple had reconciled and was living together again.

Of course, this was all good, but the underlying problems were just as insidious as before. The widows still didn’t have any source of income and there was no plan in place to change that. Was the church planning to support them indefinitely. While some of the widows were in their 60s, many were still in their 20s and 30s. What was their long term plan and did the church have any ideas how to help move them to self sufficiency? No one new the answer and no one was even asking the questions. And, while I asked the question, I was no better since I had no answers either. Similarly, while it was great that the couple was back together, the husband still didn’t have a job or even a prospect for one. While harmony was great and all, there was a young child likely going under nourished and a family barely making it from day to day. All the marriage counseling in the world wouldn’t alone fix this. (I’m feeling discouraged.)

Our next stop was to the home of a woman who was underwent fistula surgery at the clinic we saw yesterday. Oh my! We all crowded into her living room and sat on the couches as she shared about how her life had changed. At one point she literally stood up and danced, describing in effect, how she has a new life. For those unaware, I quoted both USAID’s traumatic fistula and UNFPA’s obstetric fistula descriptions here. The first is caused by rape and the second by child birth.

For this women, her marriage had been restored and was no longer ostracized by her community.

The next home we visited was with a couple that has participated in five days of “couple facilitator” training, the focus was to have them be able to help council other couples as the navigated the difficulties of marriage. More immediately, the training had impacted their own marriage, so much so that their daughter testified to the significant difference she saw in her parents. The mother especially, shared how much different things were because of her husband’s new found understanding of equality and respect. As I’ve already commented, not knowing anything about “couple’s facilitator” training, I probably wouldn’t have supported something like this if I’d known up front. In hindsight, however, I can see the impact and the importance on helping improve family collaboration and unity as the navigate the challenges of poverty.

We ended the day having dinner with Jean, the World Relief – DRC country director. This too was a great opportunity to learn more about the day to day challenges faced with serving there. Jean also shared the harrowing situation he lived through as he tried to relocate and protect his staff during the volcano in May of 2021. Lava was flowing into the city of Goma and gobbling up everything in its path, making an already challenging humanitarian situation exponentially exacerbated with a natural disaster. Ughh!!

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Entering DRC (East Africa Day 7: 2022-04-19)

April 19, 2022

After entering the Democratic Republic of Congo (DRC), we dropped our bags at our hotel and headed for a women’s health clinic. Some of IntelliTect’s philanthropy has been supporting fistula surgeries at this clinic, many of which are caused by rape. Here we met with the head doctor and discussed with her the prevalence of gender-based violence (GBV) in the DRC. In the DRC:

For those of you who are unaware, untreated fistula problems can cause you to smell constantly as your bowels are perpetually leaking. Frequently in this part of the world, your husband will disown you. Furthermore, the cause is violence or child bearing (sometimes because of rape). Here are USAID’s and UNFPA’s descriptions (not for the faint of heart):

Traumatic fistula is a condition that can occur as the result of sexual violence, often in conflict and post conflict settings. There are no solid estimates of its prevalence, but traumatic gynecologic fistula can make up a significant part of the overall genital fistula caseload in places where sexual violence has been used as a weapon of war.
Rape, often aggravated by the thrusting of objects into the vagina, can result in a hole between a woman’s vagina and bladder or rectum, or both, resulting in the leaking of urine and/or feces. Survivors of sexual assault may have additional, severe physical injuries and are at an increased risk for unwanted pregnancy and sexually transmitted infections, including HIV. Survivors live not only with chronic incontinence, but also with the psychological trauma and stigma of rape.
https://fistulacare.org/what-is-fistula/traumatic-fistula/

Obstetric fistula is one of the most serious and tragic childbirth injuries. A hole between the birth canal and bladder and/or rectum, it is caused by prolonged, obstructed labor without access to timely, high-quality medical treatment. It leaves women and girls leaking urine, feces or both, and often leads to chronic medical problems, depression, social isolation and deepening poverty. Half a million women and girls in sub-Saharan Africa, Asia, the Arab States region and Latin America and the Caribbean are estimated to be living with fistula, with new cases developing every year. Yet fistula is almost entirely preventable. Its persistence is a reminder of gross inequities, a sign of global inequality and an indication that health and social systems are failing to protect the health and human rights of the poorest and most vulnerable women and girls.
https://www.unfpa.org/obstetric-fistula

We spoke with the doctor (in yellow below) at length and she was quite open about her experiences. She talked about how the surgery was not always sufficient because in many cases when the women leave the clinic they are going back to the same crappy circumstances in which they were abused in the first place. She talked about the never-ending line of patients but the limited resources that allowed them to be treated. It was a sobering meeting.

Also, while fistula surgeries are amazing for the patients, they are not reducing the frequency of cases caused by violence. In fact, most women here are stigmatized by the problem and do their best to keep it secret. Only when World Relief (the NGO we partner with in the DRC) meets the women and is able to get to know them, do they discover the problem and persuade the patient to seek medical attention.

Afterward, we were invited to go visit some of the patients – all of whom had given permission for photos and conversations. In addition, we got to see the surgery room.

Notice that these women are still caring for their children while they are in hospital – generally a stay of up to 21 days (14 in recovery and 7 in physical therapy). While we’ve had several sobering moments throughout our trip, this was one of the worst and most memorable.

Here are some more statistics regarding DRC poverty and injustice:

In the evening, we went out to dinner with the World Relief team and discussed the various ways they are fighting poverty in the DRC. It was a great conversation and I learned about all sorts of cool things they are doing.

Earlier in the Day

I confess, that my morning was an embarrassing contrast with the clinic visit. I awoke in time to get up and watch the sunrise. It wasn’t particularly spectacular, but I love that time in the morning and it was good to spend some quiet time pondering our experience so far.