following the money & the loss of primary care

Health statistics undoubtedly show the shortage of health workers and doctors around the world. Recently I wrote about the growth of hospitals in Detroit and the huge loss of primary care physicians. This is a health issue that is often associated with countries of the “developing” world, but the USA is facing a health shortage of a different kind: access to primary care.

Health financing has had the greatest effect on disparities in health care coverage as well as the structure of the health care system. Through our health care system, physicians have been incentivized to specialize as opposed to be a general medical practitioner. As technology has made medicine more efficient, it has not reduced costs, so “fees remained high, while the time and effort required to perform […] declined (Starr, 1982). The result was an increasing income disparity between physicians who specialized (Specialists) and primary care physicians (PCPs).

The advent of federal support for health care drove the income disparities between Specialists and PCPs. In 1946, the Hill-Burton Hospital Construction Act put $4 billion into the expansion of hospitals as opposed to ambulatory services (Starr, 1982). Ambulatory care services represent the single largest contributor to the increase of hospital expenditures and to decreased performance of the health care system in both the USA and many developing countries (Karpiel, 1994). In 1965, the start of Medicare and Medicaid allowed private insurance companies to continue their practice of providing higher reimbursements to procedural Specialists than to PCPs. Primary care was further marginalized when Medicare developed a policy that linked its teaching payments to a hospital’s level of inpatient, not outpatient, services. Medicare began giving extra payments to hospitals for residency training, pushing many hospitals to increase inpatient care in order to receive higher payments.

“Primary care brings promotion and prevention, cure and care together in a safe, effective and socially productive way at the interface between the population and the health system. The features of health care that are essential in ensuring improved health and social outcomes are person-centeredness, comprehensiveness and integration, and continuity care, with a regular entry into the health system, so that it becomes possible to build an enduring relationship of trust between people and their health care providers.”

“Primary Health Care – Now More Than Ever”
World Health Organization (WHO) Annual Report 2008

In a 2008 survey of Michigan physicians, 34% identified themselves as PCPs, which follows the national trend that two thirds of physicians are Specialists (Michigan Physician Profile, 2009). The report showed that numbers had not changed since 2005 and the number of PCPs entering the workforce equaled those leaving the workforce. The report also highlighted the rising costs of medical education and the debt that many young physicians will carry into the workforce. With this high level of indebtedness, why wouldn’t younger physicians look towards becoming a Specialist as opposed to a PCP with fewer financial incentives? A friend of mine studying to become a doctor noted that many of her colleagues were having conversations about whether to go into primary care or to specialize. Unfortunately the system seems to choose the path for young doctors as opposed to giving young doctors the choice to go into a medical field that they enjoy.

Health care reform has represents a huge win for those fighting for increased access to care along with the Affordable Care Act (ACA) providing a positive framework for many living in poverty. However, the largest reform may have been one that was minimally addressed by the ACA, including 10% bonuses for PCPs under Medicare and $300 million to recruit PCPs for underserved areas. I don’t think 300 million today goes as far as 4 billion did in 1946, nor does a 10% bonus equalize decades of subsidies for Specialists. The health care reform added $11 billion in support for community health centers, but some of that was cut in the 2011 budget deal. The inability of the current health care system to keep up with this new rising demand for PCPs on top of the increase of chronic diseases and an aging population that lives longer, represents the need for reform in our health care financing not just access to health care.

We have a health system that has subsidized specialized care for too long, taken health care to large technology driven hospitals, and limited the ability for new, young doctors to infuse our health system with much needed passion. The real health care reform should have included increasing support for primary care facilities (no cuts) and more for training.

If we want all people to be able to access health care affordably then we need to provide them with the necessary health workforce that can meet them where they are. For many urban poor the Emergency Department (ED) has become their primary care facility. Many individuals working in health care finance world note the cost of ED visits is covered by the premiums of the insured (roughly $1200-$2000/ year) .

Its exciting to see widespread support for increasing access for the uninsured, its amazing to see funding to bolster primary care facilities, but  if we are going to have young doctors who aren’t living paycheck to paycheck, then there needs to be a concerted effort to get doctors into those primary care facilities and greater incentives to join the growing trend in supporting community health through primary care.

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too much health care in Detroit?

Detroit is a city where major landmarks are often its hospitals. The Henry Ford Health System (HFHS) operates three hospitals within the city limits and the Detroit Medical Center (DMC), recently bought by the private Vanguard Group, operates nine different health complexes. The St. John’s Providence group also runs two hospitals in the city. However, Detroit’s hospitals are just one side of health capacity in Detroit. The Detroit Wayne County Health Authority (DWCHA) lists thirty-six community health centers across the city, twenty of which are free or have a minimal fee to see a doctor. Not to be overlooked, Wayne State University’s (WSU) School of Medicine works with both HFHS and DMC as well as runs a number of health outreach programs for HIV, Diabetes, Asthma, Childhood Obesity, etc. to manage care for chronic conditions.

With such a wide array of health facilities and such a strong focus on health care it seems as though the population of Detroit should be one of the healthiest. Unfortunately, the socio-economic barriers faced by Detroit’s population leave it with the lowest numbers of individual with health insurance in the state, high rates of non-communicable/ chronic diseases, as well as a growing obesity crisis. From 2009 to 2010, in Detroit: median income dropped, numbers of insured decreased, and the numbers of those living below the poverty line increased. Likewise, the Michigan Department of Community Health (MDCH) doesn’t list all of Wayne County as a Medically Underserved Area/ Population (MUA/P), but much of the Detroit area has been given an MUA/P designation. So many health facilities, so little health care for the population.

American Public Media’s (APM) Marketplace and NPR’s Changing Gears ask if its health care overkill. With another new hospital proposed in Oakland County (next to Wayne County), politicians are hoping to bring in more jobs and revenue in the only sector that hasn’t been hit by the economic recession. “[…] there are already six existing hospitals within a 30-minute drive time that average occupancy is 55 percent. So it isn’t a hospital that’s needed by the community, it’s a hospital needed by one health system to capture market share from its competitors.” says Dennis McCafferty who represents a coalition of Michigan businesses and labor unions. Is it about the market or is it about access to care?

“Since about 1997, we’ve lost about 60 percent of our primary care physician capacity [in Detroit].” – Dr. Herbert Smitherman

As a result of the loss of primary care options, the cost of care is significantly increased for the uninsured. Over the past five years, Dr. Smitherman and the Health Centers Detroit Foundation, tracked 33,000 uninsured patients in Wayne County and moved 55% of them out of emergency rooms and into coordinated care through the Voices of Detroit program, which gave access to a primary care physician at reduced cost. The majority of patients are low income and uninsured, usually on medicaid. Dr. Smitherman says, “It is a very difficult population because often, when we want to adjust things and I want to prescribe a medication, they’re uninsured. People are literally having strokes and heart attacks because they can’t get access to a very simple medication. It is 50 times more costly to deal with that. It’s very frustrating as a practitioner that we don’t have the basic access to insurance products, etc. for people to cover their basic needs.”

With the Obama Administration’s health care overhaul Dr. Smitherman notes there will be added benefits for the uninsured.

About 56 percent of all those who are uninsured are people of color. Obviously, Detroit is 89 percent African American. – Dr. Smitherman

He notes that the many people who seek care in the most expensive environments: emergency rooms and hospitals, will have the opportunity to find a primary care physician instead of paying “10 to 20 times the cost” in the emergency room.

New options for the poor and uninsured are popping up across Detroit from the field of telemedicine. One such program is a partnership between CVS/Pharmacy and HFHS. CVS’s MinuteClinic’s, open 7 days a week and staffed by nurse practitioners and physician assistants, will have the added benefit of having the Henry Ford Physician Network doctors on-call. Henry Ford doctors won’t actually see patients in the clinics, but will consult with MinuteClinic staff as needed and will work with them each month to review patient charts. Patients who are visit a MinuteClinic and don’t have a primary care doctor will be given a list to help them find one. RiteAid is also launching NowClinic, which gives people a free call with a nurse or the option to pay $45 to talk with a doctor.

Governor Rick Snyder has called for better health and wellness across the state. Snyder’s proposal highlights the economic connections to a healthy population. He notes that everyone has a part to play whether business, nonprofit, or government.

Health is the foundation for Michigan’s economic transformation—it allows our children to thrive and learn, it readies our graduates for meaningful careers, and it permits our current workforce to grow and adapt to a dynamic economy. In this message, we lay the groundwork for a healthier Michigan, a Michigan in which residents of all ages prosper and contribute.

He has been innovative in hoping to create a database of children’s BMI’s to track the rise of childhood obesity and has called on the Michigan legislature to take action on a Michigan health insurance marketplace, where all can be insured to receive the proper health care. This seems to be the one area where Snyder isn’t cutting benefits for the poor or making it harder for them to access services.

To conclude, the health care landscape is rapidly changing across the State of Michigan and across the world. Many people are developing solutions to solve our lack of capacity in the health system through innovative programs and technologies. Politicians are on board, private companies are creating ideas, and nonprofit groups are making important connections for people without the right resources. What will be critical moving forward is to focus on patient needs as opposed to simple outcomes. People need solutions that they can control and maintain for themselves and their families. The future of health care must be collaborative.

the missing ingredients from Jamie Oliver’s #FoodRevolution

Since November 2010, when I started working with adolescents in the Detroit area tackling childhood obesity, television shows that deal with weight loss and healthy eating have become more interesting. I diligently watched The Biggest Loser and similar shows to re-examine the tactics they use and how successful they were.

More recently I’ve been caught up in Jamie Oliver’s “Food Revolution” because what children and adolescents eat at school is a critical piece if the current trends of obesity are going to be reversed. I’ve been very interested in Jamie Oliver’s attempt to become a healthy food “rockstar” from the UK (sorry Jamie, you can’t compete with First Lady Michelle Obama). Watching the most recent season in Los Angeles, I can’t tell you how many times I yelled at the screen about how ineffective Jamie’s tactics were or how naive he was going up against an institutionalized system.

I don’t doubt Jamie’s good intentions or his passion for the work, but if this is going to be a real revolution then there needs to be some basic understandings of behavioral change and social change as well as community engagement. I’m not sure if this is just a case of making good TV by “making noise” vs. making social change by public health, but there is room for improvement.

Behavioral Change

With the recent release of new cigarette packaging and the tactics used on Jamie Oliver’s show, it has become obvious that many people disregard research in lieu of “making noise as public health.” Any first year public health student (or someone in close proximity) could tell you that the “Health Belief Model” (HBM) of making people change their habits by highlighting fears no longer works, especially among young people. The HBM relies on scare tactics, some of the best example are from old posters from the 1940-50s that feature skeletons, sharks, and death if you don’t immunize your child, cover your cough, etc. The posters and messages worked for the time period when people were scared of new health issues and followed the messages, but we live in a different time. People don’t respond to scare tactics or negative messages. This is true across the board: in politics, with non-profits, and especially within public health interventions.

The scare tactics that Jamie uses, predictably, have minimal impact on changing people’s minds or getting more people involved. People prefer to be told what is going right or what can easily be done to make things better. Messages that empower individuals and reinforce positive behaviors are more likely to receive a respond. People want to know that they have the ability to make the changes themselves. When Jamie has a classroom discussion with adults who are facing health problems as a result of their past bad eating habits and lack of activity he fails to realize earlier that this is something the teens are facing already with their own family members. Studies have shown that young people respond even less to HBM tactics like these, largely because out of all age groups young people like to know that they have control of their lives – and they do!

Tactics for Social Change

I know its a TV show, but one man cannot make a revolution happen. Any community organizer will tell you that it takes many hands and years to make real and lasting changes to systems and structures that are doing harm. Jamie Oliver stands in a great position to include more people, spread awareness, and organize communities to work together to change their political and educational systems for better school health. However, that is not what happens. Jamie is always surprised by the low turnout and minimal impact of filling a bus with sugar or getting upset with the LAUSD superintendent. Telling parents that they are doing everything wrong won’t create community buy-in.

It isn’t until the final episode that Jamie encounters a group of parents protesting high sugar flavored milk in the schools that a first real attempt to meet people where they are happens. There are many people who want a food revolution and they are already doing the hard work. The final episode is also where Jamie brings together a group of top chefs in LA to run a competition with school cooking teams. This is a great example of the necessary coalition building and community engagement that needed to happen closer to step one.

If you want to change the policies of structure of a system, then you can’t start at the top. The superintendent, as we saw, has the power to kick people out, but not change whole policies. Jamie needed to start by building relationships with people within the system who have more power to push for change. The cafeteria workers would have been a great start. When Jamie finally met some of them, they were overjoyed with his message and could have been  a big force for change in food preparation. The superintendent wasn’t on board, but maybe one of the Board members was sympathetic to the food revolution message and could have been an important ally inside. You have to work on smaller targets before you can take on your primary target.

Building a coalition of people both inside and outside the system that you want to change is critical to making real social change. Jamie kept trying to take on his primary target, the superintendent, as an outsider with no community backing. You have to start with the hard organizing work of bringing together other influential community members, workers in the system, and individuals with power inside the system in order to effectively push for change.

Community Engagement

Throughout the whole season it was painfully obvious that the community wasn’t behind Jamie’s antics, but there weren’t very many opportunities for collaboration. Many of the points I want to make about community engagement are already listed above, but I do have one key ingredient that was missing in Jamie’s outreach.

Listening. From Jamie’s first show in LA he was telling people what was wrong. He used a series of scare tactics about school meat by waving inedible raw pieces of cow in parents’ faces. It was gross and it made a point, but it didn’t give anyone the opportunity to get involved.

Thinking back between the first show and the final show, if Jamie (or his crew) had taken the time to LISTEN and find people who were already championing the cause of better school food then he might have had a more successful season.

Conclusions

Jamie ended this season by saying, “It’s not about me. […] We all gotta start stirring the pot.” I have more hope for Jamie Oliver’s Food Revolution after the final show where he did some community listening, some great community engagement, and even some coalition building. Maybe he is even beginning to recognize that the problem isn’t all on his televised shoulders, but it is shared across the community – and they want change too.

Here are a few improvements to tactics that could revolutionize the food revolution:

  1. LISTEN to a community before acting on their behalf
  2. Focus on systems change, not just people in power
  3. Practice patience: the problem wasn’t created overnight, its not going to go away overnight
  4. Use inclusive tactics: don’t reprimand or scare

HIV solution: decentralizing treatment & patient empowerment

At the core of successful health programs are powerful community systems. Whether they are strong local governments, community-based organizations, or just informal groups of individuals – these types of community centered systems keep health programs focused on serving people and meeting needs in ways that will be most effective for the community.

In what has been called a model for Africa and US health programs by CDC Dr. Kebba Jobarteh, Mozambique is leading the way in restructuring how HIV treatment and support is delivered. Most countries in southern Africa have very high HIV prevalence rates as well as difficulties in providing treatment to those who need it. While there are many people in need of HIV treatment, there is a critical lack of adequate health infrastructure, clinics, hospitals, and health workers, to deliver the necessary services.

Providing treatment is just the beginning of the battle. Once an individual starts treatment with antiretrovirals (ARVs) they need to continue to adhere to a regular regimen of ARVs. Access to the medications and clinics along with regularly taking ARVs present a two-fold problem in areas where health services have long been weakened by a plethora of misfortunes: apartheid, structural adjustment programs, lack of development, under-investment, etc.

The new model developed by Doctors without Borders (MSF) puts communities at the forefront. By creating “patient groups,” treatment is decentralized to small health clinics in communities. This model spreads the responsibility to communities where there is the greatest need. The patient groups act as both a delivery system for ARV drugs as well as a support network for those with HIV. In many rural areas, people don’t have the time to travel long distances for extended periods of time to get their ARV drugs. The members of a patient group take turns traveling the distance to the health clinic. Likewise, members record whether each member of their group has taken their ARVs regularly and on time, which is then reported to the health clinic.

The model is very similar to that of “community health workers” (CHWs), who are members of the community that share knowledge and provide services when health systems can’t. As a solution to the inadequate health systems seen around the world, the “patient group” model puts those who need health services in control of their own treatment with the backing of a support network from their community. This may be a more effective model than CHWs since those who need treatment are providing the treatment. What better way to understand patient needs than to listen to the patients?

The CHW model has been popularized by organizations such as Partners in Health working in communities in developing countries. The model has now spread to urban areas and “developed” countries around the world. The patient model is yet another example of rural solutions from developing countries setting the bar for gaps in health care treatment in developed countries. A patient-centered/ people-centered approach to health delivery will make health systems more effective and successful around the world.

Featured on the Americans for Informed Democracy Blog, where I’m writing as a Global Health Analyst and reposted by Partners in Health.

carrenhos de chocque em mocambique (required to fight aid worker burn-out)

During my three-month long internship with a small-scale HIV/AIDS non-profit in South Africa, I visited a friend working in Mozambique with an HIV/AIDS activism organization as part of her Peace Corps placement. Beyond the entirely new experience of traveling to Mozambique, I met a very interesting crew of international development/ aid workers who gave me some great insights into who I might want to become if I entered the international development/aid arena. From working on a small operation in East Darfur, Sudan with a religious relief agency, to a technology focused firm constructing health curriculums funded by PEPFAR, to those doing backend all office-based, administrative work for USAID and the Clinton Foundation,  they were all at various stages in their lives and working in very different aspects of  development/ aid work. Some of the volunteers were in their 40s, others just out of college in Peace Corps, some had just come from extremely stressful environments where “guns were like sticks,” while others had just come to complete an internship for their Princeton graduate degree, all in all it was a motley group that gave a compelling snapshot of aid workers and the many directions they can come from and be headed towards.

4 August 2008

After walking from our hotel, my friend and I stopped at a “local” bar named Pirata (Pirate) to meet up with the motley crew of aid workers. We then headed into downtown Maputo for dinner at a restaurant recommended by one of the aid workers who had spent the longest time in and around Maputo (he had serious Mozambique cred). I had a supposedly traditional Mozambican dish of beans, rice, and shrimp which was very delicious or I was just supremely hungry from the day’s 8 hour bus ride from Johannesburg.

The Maputo based aid worker then took us to an odd sort of carnival hidden in what seemed like the middle of Maputo. It was randomly placed and not very large, but took me back to days of my earlier youth when we would visit the noise, lights, and crowds of the church carnival. We all were initially a bit shy about expressing our joy at the sight of children’s carnival games, but soon we were all reveling in the freedom from our assigned professional roles.

As we were the only ones at the carnival late in the evening, we had the whole place to ourselves. We all lined up and filled the bumper cars (carrenhos de chocque). The crackle of the electric wires, childish shouts of aid workers, and huge grins of pure joy made me realize that this should be a required exercise for all aid workers no matter if they are in the USA or based in a foreign country. We all need to take a step back every once in a while and just let ourselves enjoy being uninhibited by things as unimportant as bumper cars so that we can focus on important work.

A note for the future:

We all have to find what it is that helps us keep sharp and focused while also reducing stress, physical and emotional. The best thing to do is to schedule time when you can be unfocused, let loose, and enjoy time unencumbered by tasks, to-do lists, or responsibilities. My current job has a lot of frustrating client cancellations (currently the reason that I can sit and write this), long commutes with driving stress, and odd hours. As individuals who work in the field of aid, global health, and community development, we all want to love what we do, but the reality is that it is often a grind with harsh and far reaching social consequences that can cause us to resent a job. We all need to find those coping mechanisms that allow us to vent and rejuvenate our passions.

 

 

outsource to detroit: it’s like brazil

I caught a recent news brief from the Detroit News reporting from the Mackinac Policy Conference put on by the Detroit Regional Chamber of Commerce and was surprised by the headline.

“Outsource to Detroit”

That’s a bit different than Chrysler’s “Imported from Detroit” tagline. I’ve been following this idea and imagery of Detroit. I’ve written previously about how misinformed the image of Detroit is, some critics call this “ruin porn,” while others (some academic professors) call Detroit Michigan’s “third world” city.

For these reasons I am not too surprised to read a headline that is generally associated with sending jobs to developing countries (“third world”). The article highlights the growth of businesses moving into downtown Detroit because of the low cost of office space and the surplus of technical talent. The technical talent may be reference to wider metro Detroit and the many existing technology companies, but I know that I often see billboards in Detroit promoting web and technology job opportunities.

In an interview with Tim Bryan, GalaxE Solutions, the CEO said,

“A hundred percent of the work we’re doing in Detroit is health-care related and is coming from outside Michigan. It validates our model to outsource to Detroit.” […] enable[ing] GalaxE to serve customers for roughly the same cost as operating from Brazil.

I would not call this outsourcing, since the primary idea with outsourcing is that the job leaves the USA for another country where business is cheaper. There are plenty of examples of companies shifting locations because of varying economic climates in different States. Case in point, GM moving production from Michigan to Tennessee because of different business regulations and tax breaks. Brazil is an up and coming developing economy with its hand in many international markets – is it bad to be like Brazil?

Detroit is quickly becoming an technology hub for Michigan, which is an amazing reversal from its manufacturing past, as well as innovating for better health care. Wayne State University School of Medicine is leading incredible research projects to improve health care along with the Detroit Medical Center’s (DMC) nine specialized hospitals, Henry Ford Health System, and Michigan State University’s College of Osteopathic Medicine.

If this is the future for Detroit, then things are looking good. This is an excellent example of economic growth in a downturn via two growing industries: health care and technology. If Detroit lawmakers play the cards right, everyone in Detroit could get the best of both worlds: job creation and city revitalization. These are important steps to pay attention to for a better Michigan future.

congo is not a country

Recent research and commentary on atrocities in the Democratic Republic of the Congo (DRC) have fueled reference to a “Congo” that seems to include only one country, but “the Congo” is a large, resource rich region made up of many countries.

Traditionally “the Congo” refers to the region of Middle Africa (referred to as “Central Africa” by the UN) comprised of parts of ten (10) different countries, including: Angola, Cameroon, Central African Republic, Democratic Republic of the Congo, Republic of the Congo, Equatorial Guinea, Gabon, Sao Tome and Principe, Burundi and Rwanda.

The Congo is best understood as a geographic region, with lush tropical rainforests and a wealth of mineral deposits, that benefits from the drainage of the Congo River. As a result, interest in the Congo region has caused violence and atrocities arguably since its “discovery” by Henry Morton Stanley in the name of King Leopold II of Belgium. The King wanted to spread Western civilization and religion to the region, which has led to continually destabilization and conflict.

The geographic region known to us as “the Congo” was home to one of the advanced African civilizations as well as the Baka people (often referred to as pygmies). The Kingdom of the Kongo included parts of the DRC, Republic of Congo and Angola. As recorded by Europeans the Kingdom of Kongo was highly developed with a extensive trading network. As “explorers” and colonizers penetrated further into the interior of the African continent, the Kingdom of Kongo became a major source of slaves. As a result of political in-fighting, resource grabbing, and European invasion, the Congo region’s factions remained in civil war for almost forty years (1700).

Since European arrival, the Congo region has been in a regular flux of conflict either between political factions, against colonizers, or now among local militias fighting for control of areas of resource wealth.

Much like our misunderstandings of various aspects of the African continent, its history, and people fuel monolithic interpretations of Africa, so too do our misunderstandings of the Congo region’s governments, resources, and cultures.

Maybe our misunderstandings and myths of “the Congo” are driven by the Heart of Darkness (supposedly inspired by Henry Morton Stanley) narrative set on the Congo River that details atrocities committed against native peoples? Maybe history shows Western violence has created a culture of violence in the quest for control and resources? Either way Congo is not a country, but a vast region with deep history and amazing possibilities.

middles classes & the globalization of #winning

News agencies and development pundits have been hailing the news that one-third of all Africans are now categorized as middle class and can be compared/ compete with China and India’s middles classes. I see a number of problems with this news, the criteria used to define middle class, and the comparison between an entire continent of people and those of two large countries (both of which are increasingly involved in development in Africa). The recent report from the Africa Development Bank (PDF) says that:

34%, or 313 million Africans are now middle class (living on $2-$20 a day), after several decades without any change, a jump from 27% in 2000.

The Asia Development Bank published a similar report last year saying that 56% of the Asian population is living on $2 – $20 a day (PDF). This calls into question the definition of middle class. I consider myself middle class in the United States of America and my family has been characterized as middle class ever since I can remember. However, my family and I definitely live on more than $20 per day and I would never imagine being able to call myself middle class based on how much money I spend in a day. Its all about location. Here in the US, the term middle class is synonymous with the “American Dream.” It is not so much a hard and fast economic development term that we can use to compare ourselves with other countries, but rather a socio-cultural term that is used to compare ourselves to each other in our attainment of the “American Dream” (Western notions of success).

The Guardian cites MIT economists, Abhijit Banerjee and Esther Duflo, who point out that:

the middle classes are: likely to be less connected to agriculture; more likely to be engaged in small business activities; and benefit from formal sector employment, with a weekly or monthly salary, which enables them to adopt a longer-term perspective towards their finances.

Even with a more economic definition, nothing about the term middle class is set in stone and it varies widely between communities and countries (more economic definitions of middle class). The Guardian continued to note that $2 is the poverty line for most countries, so if you live on more than that you are middle class, but there is no in-between. This only continues to prove that “middle class” cannot be defined by economists or development pundits. If we look closer at the term in the United States, it has always been a fluid and flexible term that a wide range of the population wanted to use. The majority of Americans call themselves “middle class” even when many fall into “working” or “upper” class categories based on their income levels.

Middle class often means achieving higher education, holding a professional job position, owning a home, and having a well established lifestyle that is socially acceptable. All of these status symbols mean something different across culture and country of origin. Populations bend and shape their definition of being “in-between” poor and more well off by different standards that are generally unwritten. If we use the United States as an example again, the Pew Research Center conducted a study on social and demographic trends to find that there isn’t just one middle class in America, but four! The study found that people often held onto definitions of middle class that defied traditional stereotypes.

In conclusion, we are all middle class. Whether we want to call ourselves middle class or we truly fit the economic definition, the majority of individuals around the globe identify themselves in the middle class. There is a global middle class that has no financial boundaries, but rather includes all individuals who seek advancement, education, and something more than what they currently have. Economists and development pundits cannot create a definition of middle class for a continent let alone a country, nor can they compare the middle class of the USA to that of another country or especially a continent.

If we want to truly understand if 1 in 3 Africans are middle class, then there needs to be some serious work that includes understandings of success in various countries and asks a large segment of a country’s population how they identify their socio-economic status based on their cultural norms. Why tell someone that their success isn’t as important as another’s?

Photo credit: BBC News

More “African middle class” pictures from BBC News

four cups of tea

I had always been skeptical of Greg Mortenson’s work. Anyone who runs around the globe as a sole actor doing good works is opening themselves to lot of potential criticism. The Central Asia Institute seemed to be colonial in nature and mostly all I had heard about was how great Greg Mortenson was not about the level of success of his work. Working and studying international development, Three Cups of Tea was regularly suggested as recommended reading, but I held on to my skepticism and never ventured to read it. It wasn’t until I was working for a US based non-profit with the goal of building schools in developing countries and my older sister gave me the book for my birthday that I began to read Mortenson’s book in Nicaragua while building a school in a remote community.

It was on that trip that my fears of good intentioned non-profits that build schools came true. I witnessed first hand the manipulated stories told to better “sell” the non-profits’ good work. I saw a horrible lack of community engagement and understanding when the founder over stepped our welcome to reprimand the village leaders as if they were school children. I was appalled at the lack of respect for community members that occurred as well as the disempowerment of community members when it came to decisions related to the school building. As I was reading Three Cups of Tea I took away the powerful idea that it takes three cups of tea (or more) to really understand a community, its needs, and find the place where you can help without being an overbearing outsider. Mortenson did well to articulate the point that he went on multiple trips and met with many local stakeholders before starting construction of anything.

If nothing else I hope that Mortenson’s fame and best selling books spread this idea among the general population of people who would like to “do good” around the world. It is a complex task to take on development work and one that can’t be done lightly. Making a difference in the world takes time and patience. You have to develop relationships, meet with leaders and elders, and build credibility among a community as well as better understand community dynamics before you make a large donation let alone build a school or other structure.

Sadly there are many organizations doing more harm than Mortenson that pass under the radar because they know how to look good. Many international development non-profits can easily put on a good face by telling stories and publishing reports, but some are just as worthy of criticism as Greg Mortenson’s Central Asia Institute. We can’t continue to have organizations that seek to recreate the exotic travel and heartwarming “good” experiences over and again for their founders’ benefit. How can we better empower communities to work for themselves? How can we better educate future leaders to avoid these pitfalls of international development work? How can we learn to be quiet benefactors?