News from the Collective

In the last 20 years, global health experts have recognized the importance and encouraged the adoption of sin taxes in the fight against non-communicable diseases (NCDs) in the Global South. At the level of discourse, this is illustrated by the vast global health literature on NCDs published from the late 1990s onwards: reports and action plans issued by international organizations like the World Health Organization (WHO) and the World Bank, editorials and scientific papers in medical journals like The Lancet, and policy documents and pamphlets prepared by aid agencies, health charities, and private philanthropies. Most of these documents start by reminding readers that NCDs—chronic diseases such as cancer and diabetes associated with behavioral risk factors like smoking, drinking, and unhealthy diets—are now responsible for most of the burden of death and disability across the Global South. They then identify excise taxes levied on tobacco, alcohol, and sugar as the most effective strategy to address this burden of death and disability.

WHO poster for the 2014 World No Tobacco Day advocating for taxes on tobacco products as a strategy to lower the associated burden of death and disease.

This literature explains how—given that price is correlated with demand for tobacco, alcohol, and sugar—increasing taxes on these products will markedly reduce rates of smoking, drinking, and unhealthy eating and thereby the incidence of chronic diseases associated with these behaviors. It also stresses how sin taxes not only improve the health of nations, but also strengthen their finances. Indeed, as many of the experts cited in this literature make clear, increased taxation rates largely compensate for the decrease in tobacco, alcohol, and sugar consumption, thus allowing national governments to amass larger tax revenues that can be earmarked to finance national health systems and achieve universal health coverage. Last but not least, this literature also extols the fact that, as indirect taxes, sin taxes are relatively easy to set up and administer for governments. At the level of practice, the growing importance of sin taxes within global health can be illustrated by the mounting number of countries in the Global South—from Chile, Mexico, and South Africa to Thailand, India, and the Philippines—that have introduced taxation schemes for tobacco, alcohol, and/or sugar to combat the NCD epidemic. Many of these national schemas have been supported by international efforts such as the Bloomberg Initiative, a US$1 billion project to reduce tobacco use in developing countries led by the Bloomberg and Gates foundations, in which sin taxes play a central role.

In many ways, sin taxes are typical of the micro-technologies that have proliferated in the fields of development and humanitarian aid in the past two decades, what Stephen Collier, Peter Redfield, and their colleagues have called “little development devices” and “humanitarian goods” (Collier et al., 2017; Cross, 2013; Redfield, 2012). Indeed, like many of these micro-devices, sin taxes are meant to improve people’s quality of life, are eminently portable, and, as I discuss below, operate at the micro level, targeting individuals’ aspirations, preferences, and calculations rather than any larger macroeconomic aggregate. In this essay I shed some light on the complex genealogies of these micro-technologies by unpacking some of the political theories, scientific concepts, and ethical norms that make up sin taxes. I suggest that sin taxes are built around a particular subject—the rational actor seeking to maximize their welfare in line with their own preferences—whose origins can be traced back to the Chicago School’s microeconomic tradition and its concern with rational choice theory. In doing so, I draw on Madeleine Akrich’s (1992) concept of “de-scription” and her claim that one can find inscribed in a technical device many of the assumptions, aspirations, and values of those who designed it. In my de-scription of sin taxes I examine the work of a small network of economists led by University of Chicago professor Gary Becker and two of his collaborators, Mike Grossman and Frank Chaloupka, that was instrumental in transforming sin taxes into an accepted global health strategy. In particular, I focus on this network’s research on tobacco taxation, which was the first type of sin tax to gain acceptance in the global health field and later served as a model for excises on alcohol and sugar. I begin by showing how this research grew out of Chicago’s microeconomic tradition and Becker’s work in particular before examining how it radically transformed international tobacco control and the model of the smoker that underpins it. I conclude by reflecting on what this story can teach us about the wider history of the recent proliferation of micro-technologies in the fields of development and humanitarian aid.

Tax revenue stamp from South Africa. From Andrey Vasiunin’s online collection.

The Chicago microeconomic tradition was articulated by George Stigler, Gary Becker, and other members of the Chicago School from the 1950s onwards. As historian Steven Medema (2011:153) has carefully documented, for the earlier generations of Chicago economists, from Frank Knight to Milton Friedman, economics was the study of the “social organization of economic activity” and, in particular, “markets as coordinating devices.” This changed after the 1960s following the arrivals of Stigler and especially Becker at the University of Chicago. For this new generation, economics was redefined as the study of “human behavior” and, specifically, “rational individual choices” under “conditions of scarcity” (Medema 2011:161–162). By redefining their object of study in this way, the new generation of economists at Chicago profoundly altered their discipline (Foucault 2008). First, they made it possible to analyze how individual decisions had implications at the macro level, thus extending economic analysis within its own domain. Second, they encouraged economists to espouse an expansionist agenda and apply their methods to traditionally non-economic domains. As Medema (2011:172) has also showed, the reason for the shift of focus from social organization and markets to individual behavior and choice lies in the marked influence that rational choice theory had on many of the new generation of Chicago economists. Indeed, this “new science of choice,” articulated during the Cold War around the notion of the “rational actor,” was a “catalyst for change” in the American social sciences, where it introduced a fresh focus on and new techniques to analyze the role of individuals and their decisions in the making of complex social phenomena (Amadae 2003:5–8).

Gary Becker’s work has been central to Chicago’s microeconomic tradition (Medema 2011). Becker established the idea that economics was about the study of human behavior and choice. A disciplinary imperialist, he also believed that economics should not be limited to behaviors usually studied by economists but expanded to behaviors traditionally analyzed by other social scientists such as sociologists and anthropologists. As Becker explained, economics was about “problems of choice,” whether that was “the choice of a car, a marriage mate [or] a religion” (cited in Medema 2001:161). These beliefs strongly influenced the sort of questions (Why do individuals decide to invest in education? Why do they elect to marry and have children? Why do they choose to engage in criminal activity?) that he sought to address in his own research. The way in which Becker approached and analyzed human behavior was informed by rational choice theory. Specifically, he suggested that choices made by individuals should always be considered rational, even when they are criminal or antisocial. By rational, Becker (1992:38) meant that these choices are made by individuals who seek to “maximize welfare as they conceive it.” He believed that when doing so, individuals take into account their own “values and preferences” and anticipate as best they can “the uncertain consequences of their actions” (Becker 1992:38). He also supposed that their choices are “constrained by income, time, imperfect memory, calculating capacities and other limited resources” and shaped by “the available opportunities in the economy and elsewhere” (Becker 1992:38). For Becker, the task of the economist was to develop and empirically test mathematical models that identified and organized these different variables in a way that explained and predicted the type of behavior being analyzed.

Not until the 1980–1990s did economists systematically apply the tools and concepts of Chicago microeconomics to the study of smoking (Reubi 2013, 2016). Two interrelated bodies of work were critical in that respect. The first encompassed the studies on the demand for tobacco products carried out by Mike Grossman together with his former student Frank Chaloupka and others (e.g., Chaloupka and Grossman 1996; Lewit et al. 1981). Grossman was key in popularizing the use of Chicago microeconomics to analyze health-related behaviors, both in his own research and as director of the National Bureau of Economic Research’s (NBER) Health Economics Program. For his PhD carried out under Becker’s supervision, Grossman constructed a model of the “demand for good health” where health was a form of “human capital” that everyone possessed and could choose to invest in and increase (Grossman 1972:xiv–vx). Given his interest in health at a time when smoking had become a major public health issue in North America and Europe, it is unsurprising that Grossman subsequently chose to work on the demand for cigarettes together with Chaloupka and other colleagues. This research first established that price was a key factor for the demand for cigarettes. The research also showed that price was a particularly powerful motivator for young adults and individuals of low socioeconomic status, who have less income and are more resistant to public information campaigns on the dangers of smoking. The second body of work encompassed the studies on addiction conducted by Becker in collaboration with Grossman, Chaloupka, and a few others (e.g., Becker and Murphy 1988; Chaloupka 1990). Building on insights from rational choice theory, Becker and his collaborators claimed that contrary to popular belief, “addictions are rational in the sense of involving forward-looking maximization with stable preferences” (Becker and Murphy 1988:675). Using cigarettes and alcohol as their case study, they also built and tested a behavioral model that predicted the demand for addictive substances was greater among individuals who had “low incomes,” were “more present-oriented” and/or had experienced “unhappy” and “stressful events” (Becker and Murphy, 1988:694; Chaloupka 1990:737).

Up to this point, two very different intellectual traditions dominated the field of international tobacco control. The first, which stemmed from the field of health education, was built on the notion of knowledge or information (Berridge 2007, chapter 2; Reubi and Berridge 2016). Public health experts working within this tradition assumed that people smoked because they did not know that tobacco was harmful to their health. Following that assumption, experts believed that their main task was to ensure people were informed about the dangers of smoking. This meant educating people about these dangers through warning labels on cigarette packages, school education programs, and, most important, public information campaigns, which were deemed to be the most powerful anti-smoking measure at the time. This also meant shielding people from the tobacco industry’s marketing and public relations efforts through advertising bans and advocacy tactics to monitor and counter the industry. The second tradition, which grew out of developments in psychology and psychopharmacology, was centered on the notion of addiction (Berridge 2007, chapter 9; Brandt 2004). For public health experts and psychologists who came from this tradition, the reason people smoked, or continued to smoke, was their addiction to nicotine, the psychoactive substance in tobacco. Specifically, they contended that nicotine could, by acting on the brain via complex biomolecular pathways, control the behavior of smokers and compel them to continue smoking. For these experts, the main task was to treat this addiction, which they viewed as a pathology, by using smoking cessation techniques such as behavioral and nicotine replacement therapies.

Cover of the International Union against Tuberculosis and Lung Disease’s Factsheet on Tobacco Taxation, with the caption “Young people are most likely to quit when prices rise.”

The work on smoking carried out by Becker and his colleagues posed a direct challenge to these two intellectual traditions, leading to a rupture in and a partial reconfiguration of the field of international tobacco control in the late 1990s. To start, the work of Becker and his colleagues radically altered the view public health experts held on taxation (Reubi 2013). Until then, these experts largely ignored sin taxes as an anti-smoking measure for many reasons, ranging from ignorance about how taxation worked to discomfort about sin taxes’ regressive nature. The network of economists led by Becker helped change this perception, progressively bringing public health experts to see taxation (rather than public information campaigns) as the most potent strategy in the fight against tobacco. Grossman’s work in particular, which showed that price (rather than knowledge) was key in curbing tobacco use in groups where prevalence rates had remained stubbornly high (like the young and the poor), was critical in that respect. Furthermore, the work of Becker and his colleagues also helped establish a new model of the smoker in public health thought. Inscribed in the taxation schemes now multiplying across the tobacco control field, this model was centered on the idea of individual choice rather than the notions of knowledge and addiction associated with health education and psychology, respectively. In this new model, people smoked because they made a rational choice to do so in the sense of a welfare-maximizing calculus based on their preferences and existing circumstances. Although knowledge and addiction retained a place within this model, they were only two factors among many others such as price, education, and pleasure that could influence an individual’s decision to smoke. Moreover, it was up to that individual to determine the importance of these two factors when they weighed their options. As Chaloupka and other leading public health experts and economists argued in an influential World Bank (1999:3) report on tobacco control:

Consumers are usually the best judges of how to spend their money…. [They make] rational and informed choices after weighing the costs and benefits of [their actions]…. Smokers clearly perceive benefits from smoking, such as pleasure and the avoidance of withdrawal, and weigh these against the private costs of their choice. Defined this way, the perceived benefits outweigh the perceived costs, otherwise smokers would not pay to smoke.

To recapitulate, I showed here how a global health device like sin taxes grew out of Chicago’s microeconomic tradition and, in particular, Becker’s project to redefine economics as a function of individual choice and expand it to non-economic domains. Moreover, I outlined how sin taxes were later decoupled from Becker’s project and redeployed as a key strategy in public health efforts to fight the smoking epidemic in the Global South. This redeployment, I also showed, was accompanied by the introduction of a new model of the smoker—the rational, welfare-maximizing individual—within the international tobacco control field. To conclude, I want to reflect on how this story relates to wider historical accounts about the proliferation of micro-technologies within international development and humanitarian aid. In their writings, Collier, Redfield, and others caution against the familiar and well-rehearsed explanation that this proliferation is the result of a shift from welfare states and the social to markets and the individual (e.g., Collier 2011; Cross, 2013; Redfield 2012). Instead, they suggest that the multiplication of these micro-devices is associated with a rupture in development thought from a macroeconomic concern with large, national physical infrastructure projects to a microeconomic focus on the investments in human capital (Collier et al. 2017; see also Reubi 2016). The story of sin taxes outlined here strongly resonates with this broad historical tableau sketched by Collier and others. To begin with, sin taxes emerge from the reconfiguration of Chicago economics from a macroeconomic discipline concerned with markets as coordinating devices to a microeconomic tradition focused on rational individual behavior. It is worth emphasizing that, in the context of this reconfiguration, markets and individual choices stand in contrast to each other. Indeed, this might come as a surprise to some readers for whom markets and individual choice are necessarily—almost naturally—associated. Furthermore, it is critical to realize that the shift from mass public information campaigns to sin taxes that marked the field of international tobacco control in the late 1990s was not a shift from the social to the individual, but rather a change in the concept of the individual. It was a move away from an individual for whom knowledge always and automatically triggered certain actions to an individual who could decide not to act on knowledge and prioritize other elements such as money and pleasure instead. Last, the strong emphasis placed on individual choice in both Becker’s attempts to reform economic thought and global health efforts to curb smoking should not be interpreted as the death of the social. Indeed, in echo of Collier’s (2011) work on the post-Soviet social, the notion of the social or society has remained important for both projects, albeit in different forms. Thus, for Becker (1997:150), sin taxes are “social taxes” that can protect American “society” from the “social harms” associated with rational addictive behaviors, whereas for global health experts, sin taxes are public health “interventions” that can shield developing “societies” from the health and “socio-economic toll” of “21st-century lifestyles” (WHO 2010:vii, 37).

Acknowledgements

This essay draws on research funded through a Wellcome Trust Society and Ethics Fellowship. The essay also benefited from Stephen Collier and Peter Redfield’s thoughtful comments.

References

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Amadae, S. M. 2003. Rationalizing Capitalist Democracy. Chicago, IL: University of Chicago Press.

Becker, Gary. 1992. “The Economic Way of Looking at Life.” In Nobel Lectures, Economics 1991–1995, edited by T. Persson, pp. 38–58. Singapore: World Scientific.

———. 1997. The Economics of Life. New York: McGraw-Hill.

Becker, Gary, and Kevin Murphy. 1988. “A Theory of Rational Addiction.” Journal of Political Economy 96(4):675–700.

Berridge, Virginia. 2007. Marketing Health. Oxford, UK: Oxford University Press.

Brandt, Allan. 2004. “From Nicotine to Nicotrol.” In Altering American Consciousness, edited by S. W. Tracy and C. J. Acker, pp. 383–402. Boston, MA: University of Massachusetts Press.

Chaloupka, Frank. 1990. “Rational Addictive Behavior and Cigarette Smoking.” Journal of Political Economy 99(4):722–742.

Chaloupka, Frank, and Mike Grossman. 1996. Price, Tobacco Control Policies and Youth Smoking. New York: NBER.

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Collier, Stephen, Peter Redfield, Jamie Cross, and Alice Street. 2017. “Little Development Devices/Humanitarian Goods.” Limn 9.

Cross, Jamie. 2013. “The 100th Object.” Journal of Material Culture 18(4):367–387.

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Grossman, Mike. 1972. The Demand for Health. New York: NBER.

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Redfield, Peter. 2012. “Bioexpectations.” Public Culture 24(1):157–184.

Reubi, David. 2013. “Health Economists, Tobacco Control and International Development.” BioSocieties 8:205–228.

———. 2016. “Of Neoliberalism and Global Health.” Critical Public Health 26(5):481–486.

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Image Credits: Featured image of Gary Becker, from The University of Chicago

The Participatory Development Toolkit is a “small briefcase (26 x 33 x 10 cm) containing 221 activity cards, 65 pictures, 11 charts, 1 guidebook”; it is “covered in brown pattered cloth, with leather handle and leather snap closure.” It is decorated with drawings of women, abstract patterns, huts, trees, animals: drawings, the kit’s guide explains, “by the Warli tribe, who live in the Sahadri mountains in Maharashtra state north of Bombay” and who are “known for their mythic vision of Mother Earth, their traditional agricultural methods, and their lack of caste differentiation” (Narayan-Parker and Srinivasan 1994).

The Participatory Development Toolkit, created by Deepa Narayan, Lyra Srinivasan and others, funded by the World Bank and the United Nations Develop- ment Program, produced in India by Whisper Design of New Delhi, coordinated by Sunita Chakravarty of the Regional Water and Sanitation Group in New Delhi in 1994. This copy owned by the Getty Research Library, Los Angeles, CA.

The Participatory Development Toolkit was created in 1994 primarily by Lyra Srinivasan and Deepa Narayan, two development professionals who at the time worked for the United Nations Development Program (UNDP) and the World Bank. Unsnapped and opened, it reveals a set of 25 folders and a booklet: “Each individual envelope is coded with a number and a title on its flap.” The lid folds back to allow the kit to form a stand, and “every fifth envelope has a color-coded tab. To gain access to the materials in each set of envelopes, pull the tab and the envelopes will extend toward you” (Narayan-Parker and Srinivasan 1994). The Participatory Development Toolkit arrived at the zenith of the rage for “participatory” development. That enthusiasm lasted from the early 1970s, when the United Nations created a “Popular Participation Program” (Pearse and Stiefel 1979), to the 1980s spread of “participatory action research” (Reason 2008), to the prominence in the 1990s of the “participatory rural appraisal” (Chambers 1994) to the 2000/2007 World Bank Development Report, which incorporated “Participatory Poverty Assessments” from around the world (Green 2014; World Bank 2001). Alongside the World Bank Development Sourcebook (World Bank 1996) and a range of other handbooks and sourcebooks and kits, the Participatory Development Toolkit stands out for being an actual kit: a briefcase containing folders that reveal a range of activities, cards, photographs, game pieces, puppets (“flexi-flans”), and, especially, sets of images.

Activty #3 Cards a and b; Flexi-flans, Activity #8 sheets 1 and 2, (Narayan- Parker and Srinivasan 1994).

One can sense in the Participatory Development Toolkit an enthusiasm for inclusiveness, respect, curiosity, and a close-to-the-community style of development; these games, cards, and images are designed to draw people into discussing problems and situations that immediately affect them, to elicit stories and images of the future they would prefer to have, and to debate the solutions to the problems they experience. There are countless versions of a sort of now-and-later game: pictures of unsanitary, impoverished, violent nows, followed by cleaner, wealthier, more humane laters.

It’s not clear how often the kit (itself) was used. The games and images and techniques it contains show up in different settings across decades of attempts to install participatory development in various times and places. Many of the 25 different folders contain activities from Lyra Srinivasan’s SARAR[1] methodology, one of dozens of different packaged methods for engaging people in participation and collective uplift. Others are cribbed directly from the social psychology of Kurt Lewin, who himself inspired a generation of “participatory” research, especially in management (Alden 2012; Lezaun and Calvillo 2014).

Pump Repair Issues. Activity #19 in (Narayan-Parker and Srinivasan 1994, pp. 44-45).

But the simple fact that the kit exists at all is worth dwelling upon. Why was a “toolkit” necessary for an activity called “participatory development” in the 1990s? Who were the tool users, and what might they have done with it? Is the toolkit a device for enticing participation, for improving it, or for something else? What imagination drove its form and function, and can we learn anything from it about today’s attempts to build little development devices, or design humanitarian goods? Can we think of the Participatory Development Toolkit as a precursor to our contemporary attempts to transform development through apps, platforms, algorithms or infrastructures?

The Problem of a Participatory Development Toolkit

At the heart of this kit is a conundrum. The toolkit seeks to “scale up” and spread globally something conceived of as essentially “context specific.” Participatory development, in most of its different guises, has always resisted the idea of a uniform, universal, top-down, one-size-fits-all development. Along with many other critiques of such dreams, participatory development proposes that proper development success should depend on attending to the very specific needs of particular people. Each community, village, neighborhood, council, or agricultural extension district is its own special place, with its own special needs that cannot be simply treated just like the next. Rather, development should involve the residents in diagnosing problems and planning solutions.

A toolkit is a device for decontextualizing: it is filled with tools that can be used in multiple different contexts, tools that are standardized and hardened into a semi-universal state. But the tools are not automatic; a toolkit implies the existence of a skilled tool user as well. A toolkit sits somewhere between an imagination of a context-specific, autonomous, and self-guided development without any facilitation on the one hand; and on the other, the large-scale, universal, automatic spread of one-size-fits-all solutions everywhere. The Participatory Development Toolkit itself reflects exquisite awareness of this problem. The authors take pains to mount warnings at every turn: the kit does not stand alone; the images and games should not be used without adapting them; the kit should not be used to extract information (rather than incite participation); the user of the kit should be prepared to give up control of the kit; the kit, indeed, is not essential (see, for example, Narayan-Parker and Srinivasan 1994:1–5; Srinivasan 1990:12–13).

Activity #3, Charts 2, (Narayan-Parker and Srinivasan 1994).

In between universalism and hyper-specificity sits the kit: mediating by taking what works at a local level, attempting to quasi-formalize it, and inserting it into a briefcase so that it can be carried to the next site to repeat its context-specific success.

“Scalability” of this sort is also at the heart of our contemporary enthusiasm for apps, platforms, and quasi-algorithmic solutions to the problems of developments. The large-scale “big development” projects of mid-century, where scale often meant simply “large,” used “economies of scale” to attain a certain economization or efficiency as a project grew larger; conversely, the “small-is-beautiful” technology solutions of the 1970s counseled a return to the local, the situated, and the appropriate. But contemporary scalability sees in the small a mere instance of the large: a solution at the small scale (e.g., a LifeStraw for dirty water; Redfield 2016) can be “scaled up” and distributed globally. It is small and large at the same time. Some kinds of “tools” are scalable in this sense (software and algorithms preeminent among them), and others, perhaps, are not (dams and bush pumps).

The Participatory Development Toolkit tries to accomplish something similar: it takes a program for participation developed in response to specific cases, generalizes it, and spreads it to other sites and cases. It is “quasi-algorithmic” in the sense that it involves a set of steps in a sort of recipe, but it also relies on the existence of both a skilled tool user (the facilitator of participation, usually a development professional of some kind) and a defined group of participants (women, members of a village, a congress of delegates, extension workers, etc.). Such collectives are called into being just at the moment when the kit is in use. This process produces an experience called “participation.”

To put this contemporary problem in perspective, it is important to emphasize that there have over the decades been plenty of examples of “experiments with participation” not only in development, but also in art, in science and technology policy, in urban planning, or in the workplace (Kelty 2017; Lezaun et al. 2016). It is worth turning to the history of participatory development to understand better what these past experiments sought to achieve.

The Participation That Was

Participatory development has failed at least once already. This is perhaps not obvious to a generation of development workers or scholars discovering participation for the first time in the 2010s. In the 1970s both small, alternative groups (such as Budd Hall and the Participatory Development Network) and large organizations such as the United Nations Popular Participation Program embraced an earlier version of participatory development with enthusiasm. And as it succeeded from the 1970s to the 1990s, it came in for its own critique: by the year 2001, participatory development was being called “a new tyranny” (Cooke and Kothari 2001). The book bearing that subtitle suggested that many things had gone wrong with participation: that it had been bureaucratically routinized; that recipients were gaming the system to become “professional participants”; that it rested on a myth of community or village structure that was inadequate in most places, or to the realities of globalization, and so on. Perhaps most important, it wasn’t clear that participatory development alleviated poverty any better than non-participatory development had.

There was also a clear sense, captured best in Francis Cleaver’s critique, that true participation had been betrayed by toolkits in general:

“Participation” in development activities has been translated into a managerial exercise based on “toolboxes” of procedures and techniques. It has been turned away from its radical roots: we now talk of problem solving through participation rather than problematization, critical engagement and class (Cooke and Kothari 2001:53).

Unserialized Posters; “Fourteen pictures showing various human situations and interactions.” Activity #7 in (Narayan-Parker and Srinivasan 1994, pp. 20-21)

What were these radical roots, and how did they grow into a Participatory Development Toolkit? There are multiple interesting origin points for the Participatory Development Toolkit. The “radical” that Cleaver is no doubt thinking of is the work of Paolo Freire and more generally of “participatory action research” from the early 1970s onward (Freire 2014; Reason and Bradbury 2001). The idea that toolkit makers might try to roll up Paolo Freire and tuck him inside a kit is perhaps surprising, but actually quite obvious if one reads his work carefully. Freire’s ideas of “conscientização” dictated not just a participatory engagement with the impoverished subject, but in particular the use of imagery, games, and specific forms of contextualization. The instructions for using these images in the Participatory Development Toolkit parallel Freire’s own discussion of them in Pedagogy of the Oppressed (2014): they must be “non-directive” (i.e., not “sectarian”) and they must rely entirely on the perceptions (and “perceptions of previous perceptions”) of the “wretched of the earth” themselves. Many of the activities of the kit are directed toward instilling first an understanding of this “non-directive” form of analytical work, to be followed only later by substantive discussion of pumps, latrines, disease, and so on. Once inside the kit, however, Freire’s radical, Marxist pedagogy runs the risk of appearing lightweight and inauthentic, transformed into an exercise in “project management” ripe for critique.

Stuffed inside the kit alongside Freire is Robert Chambers, the development scholar and practitioner most often associated with the rise of participatory development in the 1980s. Chambers started life as a colonial administrator in Kenya, and it was only late in the 1980s that he began to embrace participation as a technique (Cornwall and Scoones 2011). He came to it not as Freire did, as a liberation of the wretched of the earth, but primarily as a question of ascetic practice, which is to say it was less about the participation of the impoverished villager than a form of work on the self for the development professional. Chambers was primarily concerned with “seeing reality” clearly in the hopes of transforming poverty, and he insisted that most of what development professionals did obscured reality: they engaged in “rural development tourism,” they suffered from “tarmac blindness” and “survey slavery” (Chambers 1983). They needed to be given the tools to see what was right in front of them, and to this end, Chambers advocated the flexible use of multiple different methods.

Activity #6, Diagrams 1–3, (Narayan-Parker and Srinivasan 1994)

To address this problem, Chambers pioneered a kind of “method of any method,” by which development workers could transform the simplest of techniques, like walking around and talking with people, into legitimate tools in a toolkit. Interviews, transect walks, pocket charts, ethnographic observation, and much more were lumped together and labeled “participatory rural appraisal.” The approach is clear in the Participatory Development Toolkit: there are 25 folders with different games and activities, each appropriate to a different challenge. There are also explicit directions, much like those that Chambers issued in everything he wrote, to “improvise” and adjust activities to the context and the site in question, to extend the kit and add to it, and, especially, to do so with the participation of those at the receiving end of development’s interventions.

Chambers’ approach implied that any such toolkit required a skilled tool user, and to become such a person, one had to work on oneself, develop new capacities, overcome blindness, see reality clearly, and so on. Only such transformed development workers would be able to effectively take this kit to the field to elicit the kind of participation promised by the likes of Freire (whom he recognized but did not claim as an inspiration). Despite the step-by-step nature of the toolkit (or any of the sourcebooks, scripts, or manuals promulgated as “participatory development”), the quasi-algorithm required a bit of human input: not just any human input, but that of self-reflective, awakened experts.

From the perspective of a later critic such as Cleaver, the toolkit is a proxy for the rigid, hierarchical, male engineer who sees a standard, technological solution to every problem. Participatory development—radical or not—is directly opposed to such powerful, unaccountable forms of decision-making. To the extent that the figure of the Engineer is the tool user, the toolkit is dangerous.

From Chambers’ perspective, however, the enlightened user of the toolkit can achieve a different outcome; tools are figured as neutral and emancipating when given to the right people by the right people, and the result would be the scalable development of both the professional agent and the impoverished subject of development.

Device, Toolkit, Algorithm

What is at stake in thinking of the Participatory Development Tookit as a “quasi-algorithm”? What might be the difference between a briefcase of paper games and routines for eliciting participation, and a piece of software that tries to do something similar, but is implemented on a solar-powered, GPS-enabled, data-intensive smartphone app? Can we see this kit as a vantage point from which to evaluate the contemporary explosion of various devices for development, especially those that demand the input of users concerning local conditions while using standard forms and algorithmic procedures to scale up and travel?

One obvious thing to say about the Participatory Development Toolkit is that it does not contain tools or supplies of a conventional kind. There are no hammers, pliers, or wrenches; there are no Band-Aids, gauze, or Bactine as there would be in a first aid kit; it is not quite the “kit” pioneered by Médecins Sans Frontières capable of unfolding an emergency treatment center in a remote or decimated location (Redfield 2013:69ff). Instead, it contains scripts, games, and procedures designed to elicit experiences. When opened and set into operation, it tries to create a joyful occurrence: people are called to draw pictures, make maps, play a game, or discuss a problem related to their immediate life experience and surroundings. In this respect, its “devices” are similar to what Soneryd and Lezaun call “technologies of elicitation,” or what Caroline Lee refers to as “do-it-yourself” or “designer” democracy; they are procedures and practices of convoking individuals to elicit debate, deliberation, opinion, or decision-making (Lee 2014; Lezaun and Soneryd 2007).

The toolkit is not, however, immaterial as a result. The material properties of the Participatory Development Toolkit are important; it is meant to travel, it has a handle, and it carries both its theory and its practice in easily accessible compartments and a handy users’ manual. The toolkit is not a device itself, but more like a “platform”: a box full of different devices all dependent on a similar form of action and general theory of participation. These devices are not technologically sophisticated, but neither, really, are most apps or software programs. They may depend on a technologically sophisticated infrastructure (to exist), but at the end of the day they are simple programs: devices designed to achieve particular results. What is the relation between the participating humans and the toolkit? In the toolkit, the games and images and scripts call on people to interact in specific ways. The development agents, along with those they interact with (villagers, women, engineers, farmers, politicians), are given rules, or shown images, or follow loose scripts for “non-directive” interaction with each other. The goal, or outcome, is to either diagnose a problem or propose solutions to it. It does not solve a problem diagnosed elsewhere, higher up or far away, without the involvement of people, but presumes instead that the diagnoses of a problem itself has yet to happen, or that the proposed solutions must come from the context-specific encounter itself.

This is the origin of its power: it promises a highly context-dependent exploration of problems specific to those who meet and engage in the production of these experiences. This is why it enrolls people into its project. The conundrum comes from the fact that the devices for eliciting such experiences are (perhaps unwillingly) universalized in the toolkit, made to travel. Whereas an individual development consultant might bring a set of techniques and procedures with her to a variety of (necessarily limited) places, the Participatory Development Toolkit implicitly suggests that through replication, many more people can carry these procedures to many more places.

What’s more, it is not merely a toolkit-as-commodity being replicated; it is also a toolkit funded by and branded with the insignia of the World Bank and the UNDP. These institutions make participation more or less bureaucratic, and authorize them as forms of practice. It is not clear that the Participatory Development Toolkit was required in any way, but along with manuals such as the World Bank Participation Sourcebook t(World Bank 1996) he techniques and procedures were incorporated into the standardized practices of development. One can find the same games and scripts in the Sourcebook that appear in the Participatory Development Toolkit.

The institutional standardization or participation is what provokes the suspicion of the toolkit itself, in cases such as Francis Cleaver’s critique above; rather than a highly contextualized participatory engagement, it suggests instead a bureaucratically standardized set of forms and practices, riven from the context. Soneryd makes a similar point in discussing more recent “technologies of participation”: it is not an accident that this standardization happens precisely because many actors in these organizations actively seek to “imitate and replicate” forms of participation that have worked elsewhere (Soneryd 2016:149).

Such institutional embedding (to use the new institutionalist language) is not dissimilar to the kind of infrastructural “network effects” (to use the engineering/economic language) of internet-based apps and platforms that similarly circulate plans, techniques, and procedures in the interest of producing an experience. As the kit succeeds, it draws more people into a particular form of participation, and produces professionals and networks of practice that draw on these tools as exemplary forms of participation. Both aim at scaling up and circulating the local without losing (the character of that) local specificity. But such tools are inevitably subject to both technological and institutional mimcry, standardization, and control, whether that be an audit culture of measuring results or an advertising-dependent system of revenue generation.

The Participatory Development Toolkit represents a stage in this evolution. It is “quasi-algorithmic” but not fully routine in the sense that it does not operate automatically, in the absence of context, judgment, or serendipity. Nor is it “computational” in any sense. Rather, a development agent takes the place of the networked computer: he or she runs the program (as a neutral agent: a CPU, as it were) and records the data into memory. The users of the algorithm are the participants: villagers, women, extension agents, etc. They give their data and ideas to the machine in the hopes that it will spit out a solution and perhaps some money.

The term “algorithm” used to mean a set of rules, not unlike a recipe, or the rules of a game. In this respect, the operator is like a player or a chef: some are good and some are bad. Robert Chambers’ desire to see development agents remake themselves as agents of participation relies on such a notion: you can have the best recipes in the world, and still produce a bad meal.

Open Ended Snakes and Ladders; Activity #24 in (Narayan-Parker and Srinivasan 1994, pp. 54–55)/

Lately, however, the “algorithm” has come to mean something more than just a set of steps. Rather, it is a kind of living system that depends both on computational processing of recipe-like rules, and on the constant input of many participants: participants who feed it regularly, not just use it. The Facebook timeline, to take only the most storied case, depends both on a large set of rules of searching, sorting, and comparing possible content, and on an always-changing database of what people who are connected to other people view, like, linger upon, or swipe past. This is not the same thing as a simple set of rules that depend on expert execution; rather, it seems to enable a certain fantasy of—and provoke a certain desire for—participating in an enormous, amorphous, yet nevertheless intimate collective that represents itself to itself constantly.

In its ideal version, this happens completely without human control or intervention, making the local into a universal. In reality, such “automation” reproduces the good and the bad of the local (as Facebook, Twitter, and others are discovering in the case of the 2016 U.S. election), and a reversion to the former meaning of algorithm becomes more appealing again.

Seen from this perspective, the Participatory Development Toolkit is an interesting moment in the development of devices for development. It is perhaps more like the algorithm-as-recipe in its quaint leather-bound form, but perhaps it also betrays a desire for the newer algorithm-as-system in which all over the world, people are enabled to participate constantly in the diagnosis and solution of their own problems. Or maybe it should be seen from the success of the contemporary demand for constant, unreflective participation of the sort promoted by social media. Perhaps it reveals a now nearly forgotten desire for scaling up something difficult to scale up: the reflexive practitioner whose “algorithm” is human judgment, memory, and discernment, and not an automatic, machine-learning, artificial intelligence. Perhaps it reveals a present danger of an endless participation without deliberation, whereas the analog briefcase could still, at least, contain a trace of the reflexive practitioner, the Marxist pedagogue, or the evangelical development aesthete.

References

Alden, Jenna. 2012. “Bottom-Up Management: Participative Philosophy and Humanistic Psychology in American Organizational Culture, 1930-1970” [PhD dissertation]. Columbia University Academic Commons. New York, NY: Columbia University.

Chambers, Robert. 1983. Rural Development: Putting the Last First. World Development Series. Newark, NJ: Prentice Hall.

———. 1994. “The Origins and Practice of Participatory Rural Appraisal.” World Development 22(7):953–969.

Cooke, Bill, and Uma Kothari. 2001. Participation: The New Tyranny? London, UK: Zed Books.

Cornwall, Andrea, and Ian Scoones. 2011. Revolutionizing Development: Reflections on the Work of Robert Chambers. Oxon; New York: Earthscan.

Freire, Paulo. 2014. Pedagogy of the Oppressed: 30th Anniversary Edition. Originally published 1970. London, UK: Bloomsbury Publishing.

Green, Maia. 2014. The Development State: Aid, Culture & Civil Society in Tanzania. Suffolk, U.K.: James Currey.

Kelty, Christopher M. 2017. “Too Much Democracy in All the Wrong Places: Toward a Grammar of Participation.” Current Anthropology 58(S15):S77–S90.

Lee, Caroline. 2014. Do-It-Yourself Democracy: The Rise of the Public Engagement Industry. New York, NY: Oxford University Press.

Lezaun, Javier, and Nerea Calvillo. 2014. “In the Political Laboratory: Kurt Lewin’s Atmospheres.” Journal of Cultural Economy 7(4):434–457.

Lezaun, Javier, Noortje Marres, and Manuel Tironi. 2016. Experiments in Participation. In Handbook of Science and Technology Studies, edited by Ulrike Felt, Rayvon Fouché, Clark A. Miller, and Laurel Smith-Doerr, pp. 195-222. Cambridge, MA: MIT Press.

Lezaun, Javier, and Linda Soneryd. 2007. “Consulting Citizens: Technologies of Elicitation and the Mobility of Publics.” Public Understanding of Science 16(3):279–297.

Narayan-Parker, Deepa, and Lyra Srinivasan. 1994. Participatory Development Tool Kit: Materials to Facilitate Community Empowerment. Compiled by Deepa Narayan-Parker and Lyra Srinivasan. 221 activity cards, 65 pictures, 11 charts, 1 guidebook in briefcase; 26 ´ 33 ´ 10 cm. Washington, DC: World Bank.

Pearse, Andrew, and Matthias Stiefel. 1979. “Inquiry into Participation: A Research Approach.” Technical report UNRISD/79/C.14 GE.79-2103. Geneva, Switzerland: United Nations Research Institute for Social Development.

Reason, Peter. 2008. The SAGE Handbook of Action Research: Participative Inquiry and Practice. Los Angeles, CA, and London, UK: SAGE.

Reason, Peter, and Hilary Bradbury. 2001. Handbook of Action Research: Participative Inquiry and Practice. London, UK: Sage.

Redfield, Peter. 2013. Life in Crisis: The Ethical Journey of Doctors Without Borders. Berkeley, CA: University of California Press.

———. 2016. “Fluid Technologies: The Bush Pump, the LifeStraw®, and Microworlds of Humanitarian Design.” Social Studies of Science 46(2):159–183.

Sawyer, Ron. 2011. “SARAR: A Methodology by Lyra Srinivasan.” Culture Unplugged. Available at online/play/12780/SARAR–a-methodology-by-Lyra-Srinivasan”>link.

Soneryd, Linda. 2016. “Technologies of Participation and the Making of Technologized Futures.” In Remaking Participation: Science, Environment and Emergent Publics, edited by Jason Chilvers and Matthew Kearnes, pp. 144–161. London, UK, and New York, NY: Routledge.

Srinivasan, Lyra. 1990. Tools for Community Participation: A Manual for Training Trainers in Participatory Techniques. New York, NY: PROWWESS/United Nations Development Program.

World Bank. 1996. The World Bank participation sourcebook. Washington, D.C. : The World Bank. link.

World Bank. 2001. World Development Report 2000/2007: Attacking Poverty. World Development Report. New York: World Bank.

Notes

[1] SARAR is a an acronym for “Self esteem, Associative strength, Resourcefulness, Action Planning, Responsibility.” For more on SARAR, see Sawyer’s documentary (2011).

In 2013, MOS@N, an experimental mobile health (mHealth) network providing medical monitoring and follow-up of pregnant women, was launched in the health district of Nouna in rural Burkina Faso. MOS@N is implemented by the Centre de Recherche en Santé de Nouna (CRSN), a national health research center. It is funded by Canada’s International Development Research Centre (IDRC) and supported by the Ministry of Health. MOS@N operates in an area where maternal mortality remains a major public health challenge, and where the rates of antenatal care consultation (ANC) attendance and of assisted delivery are relatively low. It aims to pilot the use of mobile devices to improve the use of health care services by pregnant women. MOS@N sends voice medical appointment reminders and health advice to “godmothers,” community relays selected as part of the project to follow up with pregnant women in their respective villages. To do so, godmothers were provided with a mobile phone and a bicycle to facilitate their movement within the village as they travel to the local primary health care center (PHC). The cell phone has prerecorded health education messages for godmothers to play when convening maternal health awareness sessions. Equipped with phones and data connectivity, godmothers can reach remote populations to provide them with health advice and information.

MOS@N also includes an electronic health record system that runs on computers installed for that purpose at local PHCs. Since none of the local PHCs are connected to the electricity grid, they were also provided solar panels to keep the computers running. Health workers—nurses and midwives—at PHCs are in charge of entering patient data into the system, which then automatically generates the reminders sent to the godmothers’ phones. In 26 villages, served by five different PHCs, MOS@N brings together pregnant women, godmothers, rural PHCs, health workers, technicians, public health researchers, server rooms, an automatic callback system, bicycles, computers, portable solar panels, batteries, cell phones and refill cards, not to mention husbands, dirt roads, bicycle repair stations, heavy rains, and village authorities, in an experimental network.

Fig. 1. The entrance of the CRSN. Photo by author.

The number of mHealth projects and systems implemented in low- and middle-income countries has doubled in the past five years. Driven by the leadership of the World Health Organization (WHO), global health organizations, researchers, and donors increasingly expect data connectivity to strengthen health systems, reduce costs for access to health care, and thus contribute to health equity. Connectivity promises to bring new bodies and populations into sight, alleviating suffering and saving lives; any obstacle to the flow of information is increasingly the cause of suffering and loss of life.

In Burkina Faso too, mHealth networks are multiplying. Most initiatives are aimed at making the national health system more data driven, with a strong emphasis on maternal and child health. In the wake of the Ebola virus epidemic in West Africa, initiatives aimed at digitizing public health surveillance and outbreak response management have also been on the rise. Organizations involved in the funding, design, and deployment of mHealth in Burkina Faso include the Centre Muraz, Terre des Hommes, WHO, Bill & Melinda Gates Foundation, UNICEF, and Grand Challenges Canada. Notable projects include the Integrated eDiagnostic Approach (IeDA), which uses mHealth devices to provide diagnostic support to health care workers and to collect data made available to public health decision makers. Another example is the integration of the WHO-sponsored Maternal Death Surveillance and Response (MDSR) into the national disease surveillance system, requiring health workers to immediately report cases of maternal death via mobile phones. The Burkina Faso Ministry of Health has been supportive of these developments, and it has recently adopted a nationwide strategy to integrate digital technologies into the national health system.

MOS@N was designed in response to a call for proposals by the IDRC to attract projects that would contribute to building evidence of the impact of digital technologies on health systems. There were three specific expectations:
 

• Access. Information and communication technologies (ICTs) suggest the projects have the potential to make health systems more equitable through better access to health care and information. IDRC takes up a popular theme within mHealth literature: mobile devices are expected to strengthen equity by reducing disparities related to cost, distance, and inadequate health infrastructure (Mehl and Labrique 2014:184). They are expected to enable relatively transparent, seamless communication, thus facilitating the provision of health services to previously underserved populations.

 

• Operational knowledge. IDRC-supported projects should contribute in bridging the gap between research and implementation. Exemplifying the rising popularity of operational research (or operations research) in global health, projects were expected to generate evidence for decision making by studying the process of implementation itself rather than focusing only on health outcomes. IDRC’s call thus insisted that selected projects should examine how ICTs were being integrated into resource-constrained settings by paying attention to the local usage and adoption of mobile technology. Although IDRC’s call was premised on the notion that connectivity should improve access to health care, it aimed to find out what “works” and what does not in various contexts.

 

• Replicability. IDRC’s call directly responded to the lack of evidence in the literature about the scaling of mHealth initiatives into health systems. The vast majority of mHealth interventions are indeed only pilot projects, and remain so. Proposals selected by IDRC were to pay particular attention to the potential for scalability or replicability. As I suggest, MOS@N indeed raises the problem of scale: How can its implementation process be replicated so that connectivity produces similar effects in different settings?

Enclosures and Expenditures

MOS@N is trying to facilitate the wireless mobility of data. However, soon after it was launched, it became evident that individuals, devices, data, and information assembled in MOS@N do not move easily. Their circulation is severely hindered, if not altogether immobilized. Obstacles are many and include poor geographical access to PHCs, considering that women often live between 5 and 10 kilometers from the nearest centers; the rainy season, when roads become impassable—sandy, clayey, if not literally flooded; a livelihood depending on women working in the fields, away from home and thus from solar panel chargers, and often from cell phone signals, too; devices that were not as portable as expected, with godmothers carrying their phones in their hands, an obstacle that some have overcome by crafting neck pouches; gender dynamics, with some husbands trying to keep godmothers away from pregnant women, or pregnant women away from the PHC; broken things, including phones, solar panels, bicycles, and computers; unreliable network connectivity; unintelligible voice messages; difficulties using mobile phones and computers; health workers lacking time to enter health data into the computer, compromising its circulation; women who won’t discuss their health status with godmothers or health workers; and conflicts between health workers, godmothers, and pregnant women. A godmother summarizes some of these obstacles:

The other day, when I was accompanying a pregnant woman, we started walking but we did not reach the Bagala PHC on time so she delivered on the road. I called the nurse at the Sikoro PHC [to which the godmother would normally take women of her village, except during the rainy season] to let her know that one of my women had just delivered on the road. I then brought her to Bagala but the nurse refused to see her. She kept asking why she delivered at home. I explained that we really were on the road to come here, and that the umbilical cord was not cut yet and her clothes were soiled with blood. But she reprimanded us, so we left. I gave my phone to her husband who then called the Sikoro nurse to let her know. In the end we brought her back home to cut the umbilical cord ourselves.

The mobility of data, which MOS@N aims to facilitate, in fact still entails the mobility of devices and bodies. And it entails significant expenditure. First, there is physical labor. MOS@N generates displacement, especially for godmothers. Although they were provided with a bicycle to facilitate their travels, the role of godmothers has gradually evolved to include the accompaniment to PHCs. As the story above shows, godmothers now walk and ride along with pregnant women. They also assist health workers during deliveries. This new role was improvised in response to the technical difficulties in generating automatic voice reminders. Indeed, as a result of many of the challenges listed above, godmothers generally do not receive the automatic reminders on time, if at all, as was initially planned. Therefore, they may spend hours on the road every day depending on where they live.

Fig. 2. Adverse Road Conditions. Photo by DAKISSAGA Judion.

Mobility in MOS@N also comes with material and energy expenditure. Batteries, cell phones, and portable solar panels are often recharged, disposed of, and replaced. Bicycles are repaired and replaced. Bandwidth is consumed. Project managers move across the district, not to mention donors, researchers, and other visitors traveling to Nouna. MOS@N also comes with a significant increase in workload for health workers, who have to enter patient data into the computer after each consultation, not to mention the tireless work of MOS@N’s field manager, logisticians, technicians, and supervisors. Improved access to health care and information in MOS@N has little to do with an easy circulation—of devices, godmothers, and messages—enabled by a stable, underlying network infrastructure. MOS@N foregrounds the corporeal and material demands of media mobility. Little devices apparently carry more than their own weight.

Media-Worlds

“Knowledge is like light. Weightless and intangible, it can easily travel the world, enlightening the lives of people everywhere” (World Bank 1999:1). It is with these words that a flagship World Development Report on knowledge for development began before emphasizing that millions of children die because of their parents’ lack of access to knowledge. Since the report was published almost two decades ago, mHealth devices have come to embody better than any other technology the medium promising such a life-saving access to knowledge. As such, they display a strong capacity to enchant and mobilize affect (Harvey and Knox 2012; Larkin 2013). The affective power of mHealth devices is directly related to their technical qualities, including their compact size and portability. Although the hype surrounding mHealth has lessened in recent years—a situation acknowledged by IDRC’s insistence on the need to determine what “works” and what does not—the underlying vision of mobile devices as fluid, neutral conduits for the flow of information remains largely unchallenged (Duclos, 2016).

In contrast to this understanding of media devices, ethnographic material on MOS@N points to a conception of media as messy, unpredictable, and transformational. In MOS@N, media devices not only carry symbols and meanings but actually shape connections and transform who/what is connected. This is partly due to the expenditures that come with failing data connectivity, resulting in godmothers still using their phones but now also walking with pregnant women to monitor their attendance to ANCs. Although we are left speculating about the effects of reliable automatic reminders, what is certain is that MOS@N alters individual and collective existence in Nouna in far-reaching ways.

A primary illustration of this lies in how godmothers are not merely connected to PHCs through mobile devices but in fact have come to think of themselves as the intermediaries between PHCs and their community: “We act as intermediaries between health workers and communities.” “The main effect of the project is that now villagers are not afraid of health workers anymore.” Or, in the words of a nurse speaking of godmothers:

Godmothers are extremely useful because here at the PHC, we do not know people in the community. Because they live in the villages, they have become our mouths and our ears with the population. …I’m a stranger here, but they know everyone. Who else could get them to participate in our activities? Now, all we have to do is call them [the godmothers].

In a sense, godmothers, not mobile phones, are MOS@N’s primary mediating devices. Godmothers of course are not passive conduits, and their work of mediation may have unforeseen effects. They spend considerable time with midwives and nurses, gaining practical knowledge and experience, but also experiencing conflicts and performing tasks not designed as part of MOS@N. Godmothers have assisted women delivering on their way to the PHC, stayed several nights at the PHC, cleaned up the PHC, and have mobilized local women as part of mass vaccination campaigns. Some have lent their phone to their children so that they could listen to music, sometimes never to see it back in working order. Others have forgotten to deliver messages, or delivered them late, or to the wrong person. Overall, though, godmothers and their phones have been described as a reassuring presence.

MOS@N has also had a significant impact on the organization of community life in Nouna. Cell phone ownership, accompaniment, and health education sessions have brought godmothers considerable social recognition. It has changed the way they are perceived. Neighbors, family members, and children borrow their phones. Some are called “doctors,” or are given small presents. In some cases, the role of godmother has come with emotional hardship. Their husbands sometimes frown upon their ownership of mobile phones. Resentment from fellow villagers is also common. Godmothers can, for instance, be accused of spreading rumors, or of deception. The confidential nature of pregnancy, the age of godmothers (in some cases younger than the women they follow), jealousy over the choice of the godmother (and her stipend and equipment), or health complications may all contribute in causing tension, and in one case even leading to the banishment of a godmother and her family from their village. In general, though, when speaking of MOS@N godmothers express sentiments of satisfaction, excitement, and deep pride. Being a godmother arguably comes with a new orientation to others and to the world.

The Futures of MOS@N

At the time of writing, funding had run out and MOS@N had come to an end. MOS@N was designed and deployed as a pilot project. As mentioned earlier, MOS@N had to improve access to health care and information to be considered successful. To a large extent, MOS@N has done just that. In addition to creating unexpected relationships, MOS@N has generated measurable public health outcomes showing significant improvement in antenatal attendance and assisted delivery rates in participating villages. MOS@N was also expected to generate data for global health donors/funders/policymakers, particularly about how it achieved this outcome, and how this process could be scaled. This is where success became harder to measure. How could MOS@N lead to something else? Can it be replicated and, if so, under what conditions?

As discussed earlier, the mobility of data in MOS@N came at a heavy cost, whether it was in terms of physical labor, or material and energy expenditure. MOS@N depends on a persistent and demanding care for the relations that constitute it as media-world. In a related manner, MOS@N relied on a high degree of improvisation, or what could be considered an “experimental” ethos. It is important to emphasize that researchers at the CRSN were aware that MOS@N remained largely experimental. Although this was their first mHealth project, they knew, because they had worked closely with local communities in the past decade, that the demands placed upon mHealth within these communities might differ from their own. MOS@N involved qualitative research aimed at exploring these demands, at examining the project’s effect, and at fine-tuning it along the way.

In other words, researchers at the CRSN were aware of what they did not know, which is the problem: now that they are looking for funding to scale the network, there is still much they do not know. They have gained implementation skills, but can they trust that “more of the same” will lead to future success when the “same” is in itself contingent and unpredictable? To what extent does the experimental ethos guiding MOS@N’s implementation lend itself to formalization? What if the way MOS@N succeeded does not suggest easy replicability? After all, MOS@N does deflate any expectation that mHealth networks can be extended in a parsimonious, predictable manner. CRSN researchers did pay close attention to the processes that breathe life into MOS@N and make it work, thus at least partially meeting IDRC’s expectation for operational knowledge. But rendering processes visible does not suddenly make these processes amenable to prediction. The future of MOS@N faces a conundrum critical to the deployment of little development devices in general: only out of fragile, messy connections do consistencies appear to emerge.

Acknowledgments

This paper is the result of a collaboration with the Centre de Recherche en Santé de Nouna (CRSN). I would like to thank Ali Sié, Maurice Yé, Gilles Bibeau, Hamidou Sanou, Moubassira Kagoné and Hélène Sawadogo for introducing me to the CRSN, and for their work which is critical to this research. I also thank the editors of this collection for their genuine comments.

References

Duclos, V. 2016. The map and the territory: An ethnographic study of the low utilisation of a global eHealth network. Journal of Information Technology 31(4):334–346.

Harvey, P., and H. Knox. 2012. The Enchantments of Infrastructure. Mobilities 7(4):521–536.

Larkin, B. 2013. The Politics and Poetics of Infrastructure. Annual Review of Anthropology 42(1):327–343.

Mehl, G., and A. Labrique. 2014. Prioritizing integrated mHealth strategies for universal health coverage. Science 345(6202):1284–1287.

World Bank. 1999. World Development Report 1998/99: Knowledge for Development. New York, NY: Oxford University Press.

Image Credit: Panel from The White Ribbon Alliance for Safe Motherhood Burkina Faso, Section Kadiogo. Click to view full image.

Innovation by Design

In 2012, the United Kingdom’s Department for International Development (DFID) launched its Innovation Hub (i-Hub). It thereby followed a trend among development actors who see innovation, broadly defined as generating new ideas leading to large-scale solutions, as crucial to increase the impact of their interventions. In the words of Judith Rodin, former long-time president of the Rockefeller Foundation, “Innovation alone will not solve all of the problems facing humanity, but we certainly won’t solve many without it” (2016:6). In contrast to mainstream innovation that does not pay attention to existing inequalities and can thereby exacerbate them, academics and practitioners are increasingly using the term “inclusive innovation” to describe innovation practices that explicitly aim to improve the lives of marginalized groups. Having subsumed terms such as “pro-poor,” “below-the-radar,” “grassroots,” or “frugal innovation,” inclusive innovation refers to “the inclusion within some aspects of innovation of groups who are currently marginalized,” either through products and services developed specifically for them, their incorporation into the innovation process, or support for their own grassroots innovation efforts (Foster and Heeks 2013: 335).

This innovation turn is often joined by the embrace of humanitarian design, which is the application of design methods to development ends or—as designers would say—to change what is into what ought to be. Humanitarian design has its historical roots in longstanding alternative design traditions such as universal, ecological, or feminist design. E. F. Schumacher’s Small is Beautiful (1973) and Victor Papanek’s Design for the Real World (1984) called for the use of socially and environmentally responsible technologies and design. Papanek himself designed a 9-cent radio made of a used tin can and powered by wax or animal dung burned underneath it, which was distributed by UNESCO in India and Indonesia. The tin-can radio can be seen as an early humanitarian device and the forerunner of the hand-crank or solar-powered radios now ubiquitous in many places in the Global South. More recently, when Melinda Gates and Paul Farmer were asked what they saw as the innovation that is changing most lives in the developing world, they answered, “human-centered design,” in reference to a particular brand of humanitarian design advocated by IDEO.org (Wired 2013).

IDEO.org is the nonprofit subsidiary of IDEO, a Silicon Valley–based international design consultancy that has been one of the most successful commercial entrants into the humanitarian design space. Its DesignKit website (www.designkit.org) provides popular online courses, field guides, and case studies. Through these free resources and articles in leading magazines such as the Stanford Social Innovation Review, IDEO has played an important role in legitimizing the participation of professional designers in the development enterprise. In the latter publication, IDEO Chief Executive Officer Tim Brown and IDEO.org Executive Director Jocelyn Wyatt argue, “Time and again, [development] initiatives falter because they are not based on the client’s or customer’s needs and have never been prototyped to elicit feedback” (Brown and Wyatt 2010:31). By branding its own approach as human-centered design (HCD), IDEO.org makes explicit—and appropriates more visibly than other organizations in this space—the critical centrality of user perspectives in humanitarian design.

Part of the legitimation process of humanitarian design is redefining the development problem as a shortage of creative ideas, flawed system design, and preconceived notions of development practitioners (Schwittay 2014). In addition, advocates of humanitarian design point out that the complexity and fast-paced nature of today’s development challenges calls for innovative, creative, and integrative experts—designers in short—who are best placed to tackle the problem of persistent poverty. Part of their approach is to redefine common constraints, such as poor people’s inability to pay for necessary services, as “creative springboards” and to redefine poor people’s needs as (commercial) opportunities. This vision of development is based on a conceptualization of the poor as consumers and an individualization of infrastructural problems, both hallmarks of humanitarian goods.

Amplifying Development

In 2014, DFID’s i-Hub contracted IDEO.org to the tune of £10 million to develop and implement its flagship program, Amplify (www.amplify.org). Amplify is a crowdsourcing platform aimed at engaging nontraditional development actors such as designers and other creative entrepreneurs, diaspora communities, technologists, engineers, and the public at large. It also wants to establish stronger connections between these actors and potential users of the development solutions generated via the platform. By definition, these users are constituted as poor to fit DFID’s mandate. Reflecting the hyperbole that often surrounds the uptake of innovation and design in development, Amplify’s business plan marketed the program to DFID senior management as a “platform [that] could galvanise truly transformational and unprecedented innovation by attracting new sources of expertise” and the use of collaboration (Amplify 2013). Indeed, Jonathan Wong, former head of i-Hub, reports that thanks to Amplify, HCD is diffusing across DFID and other UK government departments (IDEO.org 2016). This is also a process of making visible the informal and unseen practices already happening at the margins of many development organizations, of mainstreaming them and showing their potential contributions to DFID’s work.

The Amplify platform has been adapted from the original OpenIDEO platform, which was built to stimulate “open innovation” and uses proprietary software and a Creative Commons license. Calling it an online platform rather than a website highlights such crowdsourcing devices as socio-technical spaces that enable diverse and dispersed groups of people to collaborate on joint projects. Amplify itself consists of eight challenges, with topics ranging from women’s safety in urban areas to improved refugee education to youth empowerment in East Africa and enhanced opportunities for people with disabilities. Each challenge goes through a four-month online process, at the end of which a handful of winners attend a design bootcamp, usually held in Nairobi or Kampala, and receive upwards of £100,000 in DFID funding and IDEO design support to implement their ideas. To date, seven challenges have been completed, which allows us to examine if and how the program’s use of open collaboration and humanitarian design have been changing DFID’s modus operandi. Our analysis is based on more than 2 years of qualitative research, encompassing in-person and Skype interviews with three DFID managers, five IDEO managers, and 15 participants, predominantly finalists of the first four challenges. We also conducted detailed numerical and discourse analysis of three challenges through online research and examined secondary materials such policy papers, a business plan, blog posts, YouTube talks, and online meet-ups.

Fig. 2. Participants in the 2016 Amplify Bootcamp in Kampala, Uganda.

Most obviously, the Amplify application process differs significantly from DFID’s traditional Requests for Proposals. The latter ask for precisely defined project descriptions and timelines, budgets, and objectives, all presented in development jargon that from the outset narrows the pool of applicants to those able to comply with these requirements. Instead, Amplify’s more flexible and open-ended process emphasizes learning and iteration. Most participants—theoretically anybody with an internet connection can set up a short profile and join the platform, although there are clearly structural constraints to participation—post preliminary ideas on the Web2.0-type website. There are a number of free-form text boxes where participants answer open-ended prompts such as, “Explain your idea,” ‘“Who benefits?” and “How is your idea unique?” In addition, dropdown menus provide more precise information about the participants themselves on, for example, years of experience in the country for which the idea is being proposed, expertise in the sector, and size of operating budgets. Although written text, which has to be in English, dominates the submissions, participants are also encouraged to embrace more visual language by posting photos and short videos. All shortlisted participants have to provide a user-experience map to chart how potential users of their idea would participate in the proposed project. Initial submission can easily be changed using a simple editing function in response to questions and comments from other participants and IDEO.org managers, which are displayed in a comment section.

Fig. 3. User experience map created by a Food for Education, a winner of the fourth challenge.

This online process is structured according to the HCD process of Ideas–Feedback–Improvement, which asks that participants show how comments and other feedback are shaping the evolution of their ideas. Although this structure imposes its own logic, it is miles away from the conventional log frame (logical framework) used by many development organizations. Whereas log frames demand that information is presented in boxes, organized by technical terms such as input, outputs, and outcomes, the design process operates through freeform, flexible thinking and writing to produce more open-ended submissions. Several participants we interviewed welcomed this move toward a more realistic process for formulating and implementing development projects, which one participant described as “learning rather than proofing.” Such learning also takes place at the level of the program, as Amplify itself has been conceived as one large prototype where continuous adjustments are made from one challenge to the next.

Amplify’s aim has always been to fund small organizations that DFID, which channels most of its aid through large international nongovernmental organizations (NGOs) or consultancies, is not usually able to support. An examination of the 30 winners of the first five challenges shows that just over half are nonprofit/NGO-type organizations, eight are social enterprises, three are professionals, and another three are design groups. A group of New York University (NYU) design students won the first challenge with a project developed in collaboration with a Nepalese NGO they had met on the website; this was celebrated in a newspaper article as being exactly what Amplify was about (Leach 2015). However, an IDEO manager complained to us that the program should instead be supporting Kenyan design students and connecting them to Kenyan social enterprises. He was not so much objecting to the fact that funds went to the United States rather than target countries (most of the money was channelled via NYU to the Nepalese organization), but that the U.S. students did not know much about what is going on in Nepal. It is through such internal debates that small, community-based organizations have emerged as the “sweet spot” targeted by Amplify, showing how inclusive innovation and open collaborative practices can generate their own politics of exclusion. In the fourth challenge, a Kenya-based design group called KDI did win, with a project to work with Nairobi slum dwellers to redesign open spaces to prevent flooding.

Fig. 4. Page from KDI’s pilot concept plan submitted to IDEO.

Small Experiments

i-Hub’s first head has described Amplify as “less like Encyclopaedia Britannica and more like Wikipedia” (Wong 2016:125). For him, development knowhow is no longer created in traditional centers of power, which instead “curate” knowledge production in multiple locations around the globe. However, the above description of what is new about the program also reveals some of its continuities with more conventional development regimes. Most important, Amplify expertise remains firmly situated in the Global North, with IDEO.org designers in New York and San Francisco, DFID managers in London, and unnamed subject experts who ultimately chose the winning ideas. This replication of authoritative development geographies can also be seen in the location of the finalists. Although all of the winners of the first five challenges are based in the Global South, 24 of 30 have a connection to the Global North, with 19 to the United States. Close to 50% of all winning projects are located in Kenya, despite the fact that 27 of DFID’s priority countries are eligible for Amplify support. The sixth challenge focused on four countries in East Africa only, narrowing down Amplify’s professed diversity to long-established sites of UK development interventions.

Amplify is also subject to a tension at the heart of the design endeavor. On the one hand, there is an insistence that everyone is a designer because design is a fundamentally creative, human activity, which awkwardly stands counter to claims by professional designers that they possess the right qualifications, skills, and methods to solve the world’s problems. Although everybody who logs onto the Amplify website has to participate in its designer-y process, it is IDEO.org employees who are the program experts. Such an appropriation of expertise resonates with condemnations of humanitarian design as “soft cultural imperialism” operating through neoliberal narratives about poverty and the use of techno-scientific market devices to solve it (Johnson 2011:463). However, one characteristic of humanitarian design is precisely the ever-closer entanglement of markets and morals (Redfield 2016). In addition, it is Silicon Valley’s techno-utopian and libertarian values that shape Amplify’s operations and thereby seep into broader international development efforts.

Accordingly, Amplify’s business plan celebrates its “start small, test, and fail early” mentality (Amplify 2013). Continuous experimentation is encouraged throughout the online process and especially among finalists. In our interviews, some participants recognized the challenges that such an experimental logic can present in the complex world of development, where vulnerable livelihoods leave little room for creative destruction. There is also a qualitative difference between the beta version of the latest geolocation app failing in tests with a consumer focus group, and the implications of discontinuing a project that was providing important community services. In one case, Amplify managers urged a finalist to introduce a new employment skills project requiring substantial upfront investment in equipment against the finalist’s own judgment that it would not be economically sustainable in the long run. Having to abandon the project after the three-month period supported by a small Amplify grant resulted in confusion and disappointment among its users. The organization’s own frustration echoes critiques that humanitarian designers, in their search for marketable innovations, sometimes do not pay enough attention to financial sustainability and organizational cultures (Mulgan 2014).

Above all, Amplify operates as a micro-social generator, incubating interventions at a micro scale. It combines the qualities of a social networking platform (like Facebook/Linkedin) with the features of an open-editable content platform working through the small contributions of numerous individuals and groups and overseen by a group of administrators (like Wikipedia). By design, it supports small organizations producing local solutions that improve the lives of individuals, their families, and their neighborhoods. On the one hand, this results from the nature of design. DFID managers recognized in our interviews that design can only tackle more technical problems, and Amplify was always aimed at particular locales rather than universal coverage. This is not to say that it does not have global ambitions, as scalability is something experts look for in winning ideas. Indeed, one finalist of the Refugee Education challenge, a Jordanian organization called We Love Reading, is aiming to build a global movement to get more children to read for pleasure. But it also remains firmly rooted in its local origins: it started in a neighborhood mosque in Amman, and works through one reading circle at a time.

Fig. 5. Image from presentation prepared by IDEO.org for We Love Reading.

On the other hand, micro is the scale of humanitarian devices, and similar to these devices, most winning ideas on Amplify advocate for solutions standing apart from state infrastructures or authorities. Working at an individualized and individualizing level, they deploy technical minimalism in the face of immediate needs. They also often create “micro-scale market opportunities” while presenting “small…approaches to social change” (Redfield 2016:179). How has this translated into the production of humanitarian goods?

Designing Humanitarian Devices

Among the winners were certainly devices that fit the inclusive innovation remit with its focus on newness: a clean birth kit for poor Indian mothers, a biogas-powered milk chiller for Tanzanian farmers, novel storage solutions for Ethiopian market vendors, a market-matching chatbot connecting Kenyan poor farmers with buyers, and a peer-to-peer SMS-based information network to alert Jakarta inhabitants to floods. But the great majority of winning projects have been quite conventional, from employment training schemes to microfinance to community health initiatives and educational programs. This reflects Amplify managers’ self-professed scepticism towards technological silver bullets and existing expertise within DFID more broadly, which ultimately limits what can be funded. Equally important, because of the organization’s value-for-money mentality stemming from its fiscal responsibility to UK taxpayers, initial blue-sky thinking has made way to safer ideas and organizations. Has this resulted in poor—rather than pro-poor—innovations, foregoing breakthroughs for incremental change? Although Amplify’s outcomes might be familiar, the process by which they have been achieved is certainly new to DFID, many of the winners, and the platform’s observers.

And what if we regarded design as a particular, “remedial” approach to changing situations whose status quo cannot be accepted, as suggested by Bruno Latour (2008)? Then, rather than being revolutionary, humanitarian design can be seen as careful in a double sense: on the one hand it can only present limited solutions to clearly circumscribed problems, and on the other it is infused with an ethics of care that accords well with the affective dimension of contemporary humanitarianism and the popular embrace of poverty alleviation causes. It can be seen as an approach to international development whose practitioners wonder whether they are asking the right questions where others have ready-made answers, who examine the assumptions that most development interventions take for granted, and who hold in view the messiness and complexity of any project of change, ultimately recommending to proceed with caution. Likewise, for researchers of these approaches, rather than subscribing to the well-trodden critique of neoliberal market dominance, might an agnostic stance that explores their potential while acknowledging their limits be more productive?

References

Amplify. 2013. Business Plan. Available at link.

Brown, Tim, and Jocelyn Wyatt. 2010. “Design Thinking for Social Innovation.” Stanford Social Innovation Review 8(1):31–35.

Foster, Christopher, and Richard Heeks.2013. “Conceptualising Inclusive Innovation: Modifying Systems of Innovation Frameworks to Understand Diffusion of New Technology to Low-income Consumers.” The European Journal of Development Research 25(3): 333-355.

IDEO.org. 2016. Impact: A Design Perspective. Available at link.

Johnson, Cedric. 2011. “The Urban Precariat, Neoliberalization, and the Soft Power of Humanitarian Design.” Journal of Developing Societies 27(3–4):445–475.

Latour, Bruno. 2008. “A Cautious Prometheus? A Few Steps Towards a Philosophy of Design (with Special Attention to Peter Sloterdijk).” In Proceedings of the 2008 Annual International Conference of Design History, pp. 2–10. Boca Raton, FL: Universal Publishers.

Leach, Anna. 2015. “Collaboration Not Competition: Could This Be the Future of Development?” The Guardian, April 14. Available at link.

Mulgan, Geoff. 2014. “Design in Public and Social Innovation: What Works and What Could Work Better.” Available at link.

Papanek, Victor. 1984. Design for the Real World: Human Ecology and Social Change. Chicago, IL: Academy Chicago Publishers.

Redfield, Peter. 2016. “Fluid Technologies: The Bush Pump, the LifeStraw® and Microworlds of Humanitarian Design.” Social Studies of Science 46(2):159–183.

Rodin, Judith. 2016. “Foreword.” In Innovation for International Development: Navigating the Paths and Pitfalls, edited by Ben Ramalingam and Kirsten Bound, pp. 6–7. London, UK: NESTA.

Schumacher, Ernest Friedrich. 1973. Small is Beautiful: A Study of Economics as if People Mattered. US: Random House.

Schwittay, Anke. 2014. “Designing Development: Humanitarian Design in the Financial Inclusion Assemblage.” PoLAR: Political and Legal Anthropology Review 37(2): 29-47.

Wired. 2013. Interview with Melissa Gates and Paul Farmer. Available at link.

Wong, Jonathan. 2016. “From Britannica to Wikipedia: How Traditional Development Players Are Catalysing Collaboration for Innovation.” In Innovation for International Development: Navigating the Paths and Pitfalls, edited by Ben Ramalingam and Kirsten Bound, pp. 120–130. London, UK: NESTA.

Featured Image: Image from IDEO.org 2016 Impact Report (IDEO.org 2016). “Design: We improve the lives of people in poor and vulnerable communities through the solutions we create.”

The labyrinth of foil inside a glucometer strip reveals a fragile chemistry. If you peel open the plastic covering, many inner circuits contain some version of biosensor technology, electrochemical cells screen-printed with gold or other precious metals and coated in places with enzymes. The foil serves as a conductor for electrons in a drop of blood, allowing a brand-matched glucometer machine to measure the charge a sample holds.[1] Yet costly design components (including gold) are also part of the reason that glucometer strips remain too expensive for most people in the world who have diabetes.

Fig. 2. Diabetes mortality. World Health Organization 2014. Used with permission.

Today, personal blood glucose meters are widely considered best practice for optimal diabetes management. Key in calibrating safe insulin dosing, they have also become a vital part of how people with diabetes move in and out of numerical legibility: glucometers are playing a major role in the piecemeal global public health mapping[2] of a diabetes epidemic rising worldwide. Even with increasing bureaucratic recognition, the number of people with diabetes remains debated by major policy institutions. The World Health Organization, author of the concerning map above (Fig. 2), calculates some 1.5 million fatalities from diabetes each year, while the International Diabetes Federation (IDF) places its projections even higher. Trying to account for undiagnosed populations, they estimate that diabetes now kills around 5 million people worldwide annually—five times as many as the reported mortality from HIV/AIDS in 2016—and that some three-quarters of an estimated 415 million diabetics today are living in low- or middle-income countries (IDF 2015). These very different statistics help to show the murky contours of a vast epidemic that glucometers’ measures both enter and play a part in enacting (Mol and Law 2004). Yet their role in frontline diagnosis also hinges on a painful irony: glucometers’ metrics help to make visible an enormous population of people living with diabetes in contexts of poverty, many of whom cannot consistently access the same meters then vital for day-to-day care.

Fig. 3. “Cash for diabetic test strips” sign at Pennsylvania intersection (photo by author).

I first encountered these issues as an anthropologist following people’s stories about living with diabetes during a year of fieldwork in the Central American country of Belize. It initially came as a surprise to me how expensive and out of reach the basic tools of glucose home management remained for many people I spoke with in 2010. During this time, glucometer machines—some purchased at grocery stores or local clinics, others acquired from visiting care groups or sent by relatives in the United States or elsewhere abroad—were priced around $50 to $100. Some corporations even provided them for free if you bought enough test strips, which are the truly expensive component of this system. Prices are declining today, but in 2010, they went for around $50 to $70 per jar of 50 strips (which would last less than a month for someone testing twice a day, but were often stretched much further by people trying to make supplies last). They had to be constantly replenished with imported strips that require precise matching to machine model and brand (Moran-Thomas 2016). A thriving gray market (Grondahl 2012) flourishes around them even in the national contexts they are specifically designed for, a problem reflected in the image I took recently in Pennsylvania (Fig. 3). According to a CNN report, in 2012 diabetes test strips became the number one most frequently stolen item in the United States, surpassing alcohol and cigarettes (and raising disturbing questions about the systems in place when a top target of criminalized theft is entwined with health-seeking behavior).[3]

Although glucometers first seem like the closest thing there is to a “solution in a box” (Redfield 2012a) for global diabetes management, as Peter Redfield (2012b) puts the quest for such objects, their upkeep entails engaging a transnational supply line full of expensive, complex parts and hardwired assumptions. Though portable, these devices require intricate networks to maintain: codes and calibrating fluid; lancets to draw blood from fingertips (for which some people substituted pins or sewing needles); and lithium and other specialized imported batteries, for which there was no substitute. Managing these messy assemblages could become a family affair, including the coordination of foreign insurance plans and mailed parcels. Certain models became easily damaged in hot temperatures, or left people trying to recode their machine’s time stamp, which might allow recently expired strips to come back into circulation. Many said a jar that expired a day or two ago could still work just as well, but no one knew exactly where to draw the line at when a strip’s diminishing efficacy became too far expired to be worth consulting: A month? A year? Of course, drawing such lines returns to much larger unsettling questions around about glucose meters: How bad is less than ideal care—and how are people navigating its risks against the de facto dangers of no care? I wasn’t sure what the implications of expiry backdating were in practice, but observed many cases in which refusing to fiddle with a meter would have meant no way to test at all.

Glucose meters were not designed to enter humanitarian aid economies. After all, diabetes had not historically been imagined as a worldwide issue of humanitarian concern. Decades ago in the 1970s when early blood glucometer models were first being developed in Europe, North America, and Japan, diabetes was still largely considered a “disease of affluence.” Historically portrayed as linked to excess—if anything, the opposite of malnutrition—Type 2 diabetes was frequently cast as the responsibility of misbehaving individuals rather than a societal concern or urgent public health issue. Meanwhile, people with Type 1 were often mistakenly imagined scarcely to exist outside high-income contexts.[4]

In U.S. settings today, glucometers are often used in conjunction with continuous glucose monitoring systems or even insulin pumps. But these, to my knowledge, were not available in Belize even to the wealthiest, making a working “finger prick” meter more important as a checkpoint. For those who could acquire these digital devices, they commonly indexed the generosity of relatives abroad or served as artifacts of transient philanthropic interventions, networks difficult to sustain day in and out. I saw countless machines that were unusable or broken. Time and again, I encountered malfunctioning meters with elaborate features such as Bluetooth compatibility on the shelves of homes without electricity, artifacts of vast gaps between the contexts these machines’ designers envisioned and the places they have become necessary. Stored on kitchen shelves or carried in weathered plastic bags by patients trying to repair them, people’s bodies and devices often seemed to be wearing out together.

There is a story about a critical crossroads in the history of meter development. It is an oral history that perhaps might be read as an aspirational rumor, but the story goes like this: There were two major competing companies shaping design when the first glucometer machines came out, one in England and another in Germany. A top employee of the British company has described how their engineers proposed making an open machine that would read either company’s strip, and called their German counterpart with a proposal to coordinate. According to his recollections, the German company turned down the idea and did not want their strips read by any but their own machines (Mendosa 2006).

Although meters philanthropically donated by manufacturers today provide key islands of care in select low-income pockets of the world, such programs remain highly proprietary and heavily dependent on donor control, leaving huge populations excluded. There are also important efforts under way to distribute glucose meters that reflect the hard work and care of innovative grassroots communities in Belize and beyond, but such collectives still deal with devices that are prone to systemic breakdown and remain out of financial reach for many in the world. Scholars such as David Fidler (2008) have envisioned a productive “open source anarchy” that might characterize global health governance, in which private and public institutions alike could collaboratively contribute to building health networks and catalyzing competition to drive technological innovation. But the case of brand-matched strips and proprietary glucometer parts for global diabetes care seems more iconic of what Ruha Benjamin (2015) calls “discriminatory design,” technologies with foreseeable injustices built in. (And like many forms of discrimination, taken-for granted norms and complacencies that exclude certain populations from access can produce worrisome effects without being deliberately unjust.)

Is “discriminatory design” the inverse of humanitarian design? Humanitarian impulses express conscious intent to remedy injustices, whereas a glucometer’s discriminatory effects seem to derive more from assumptions and failures of imagination. As Madeleine Akrich observes in her now-classic essay “The De-Scription of Technical Objects” (1992), it is often “only in the confrontation between the real user and the projected user [that] the importance of…the difference between the two [comes] to light,” taking ethnographic work to “follow the device as it moves into countries that are culturally or historically distant from its place of origin” (Akrich 1992:211–212). When design problems for poor patients are identified, what happens next? As Alice Street discusses in this issue, point-of-care diagnostics have become a frontier of innovation for various global health projects. Yet glucose meters stand out as a boundary case example of technological design that has not been transformed by these new norms. Glucometers also serve for much more than one-time initial diagnosis of diabetes (though they at times play a diagnostic role): people then require access day in and out for the rest of a lifetime, if they hope to monitor their blood sugar in the ways their doctors recommend. Why have affordable, portable diagnostic tests for human African trypanosomiasis been developed and manufactured, but not for blood glucose?

Some people ask whether a satisfactory low-cost version of glucose testing already exists in urine strips (freighted with their own history of technical and ethical conundrums). Some of the first known technoscientific testing for diabetes was conducted with urine and bits of sheep’s wool dipped in stannous chloride, which turned black to indicate the presence of sugar. Urine tests using paper steeped in alkaline indigo-carmine were in vogue by 1883, when Bedside Urine Testing was published in England (Clarke and Foster 2012). The messy material culture of boiling your own urine was finally replaced in the 1940s by an Ames company urine dipstick test for sugar, the Clinitest. It was based on the breakthroughs of dry-reagent chemistry (the technology behind litmus paper), and popularly marketed for home use.

Figure 4. Clinitest, 1942. Gift of Robert J. Locurto, Division of Medicine & Science, National Museum of American History, Smithsonian Institution. Used with permission.

Today’s blood glucose machines are far more accurate than urine tests because they provide “real-time” blood glucose levels, whereas urine (by the time it’s expelled) is reflecting the body’s state several hours before. This, along with other limitations in precision, now makes blood glucose meters a basic standard of care for home testing in the United States. But out of recognition that such everyday glucometer testing remains utterly out of reach for many poor patients in huge swathes of the world, one of the IDF’s important advocacy and policy engagements was to issue a position statement on glucose testing access. It boldly supported the use of urine testing at home for diabetic people who could not afford personal blood glucose meters. The IDF’s official position statement on urine glucose testing was publically issued in 2005. The three-page document reads in part:

Before the advent of blood glucose monitoring in the 1970s, urine glucose monitoring was universally used, with many people able to maintain good control. Blood glucose monitoring has now replaced urine monitoring in resource-rich settings. However, insistence on blood glucose monitoring in economically disadvantaged settings could result in no monitoring at all…

• Urine glucose monitoring should continue to be available throughout the world.
• Education about its role and appropriate use should be part of essential education about diabetes for health care professionals and governments.
• It can be used separately to, or in conjunction with, blood glucose monitoring in particular circumstances and settings.
• It should continue to be included on the World Health Organization Essential Drugs List.
• The major promotion by industry of blood glucose monitoring should not result in the appropriate role of urine glucose monitoring being underestimated.
• As long as results are interpreted correctly, and limitations understood, it provides valuable information in persons with type 2 diabetes treated by diet or diet and tablets, in people with type 2 who use insulin, and in people with type 1 diabetes, who cannot afford blood glucose testing…
• Because it is significantly cheaper than blood glucose monitoring, it has a very important role to play in settings where blood glucose monitoring is not accessible due to cost, or where blood glucose monitoring can only be done relatively infrequently. This occurs in some situations in both developing and developed countries.
• Its use should be determined by the individual healthcare professional in conjunction with the person with diabetes, taking into account all circumstances.

International Diabetes Federation, 2005.

The IDF affirms they have not updated this statement, though it is not widely publicized. (Perhaps this relates to diplomatic negotiations with glucometer manufacturers, key players in diabetes policy arenas today.) Yet controversies about digital glucometer machines versus urine testing are also tangled up in much larger debates in global health ethics: When is outdated basic technology a stopgap measure for pragmatically addressing inequality in the meantime, and when does it risk normalizing complacency with unequal standards of care?

The glucometer’s historical emergence in high-income contexts sets the stage for certain kinds of innovation being constrained around industrial players’ concerns with retaining control of lucrative markets. Yet Akrich argues that it can be easy to believe such norms are unchangeable, which makes social history useful for opening up the contingencies of past designs and suggesting how their contours may be fiddled with ahead: “processes involved in building up the technical objects are concealed. The casual links they establish are naturalized. There was, or so it seems, never any possibility that it could have been otherwise” (Akrich 1992:222). Indeed, even market realities do not put to rest the larger questions also at play: Which inequalities trouble people into action or outrage, and which ones do not? Obviously there are unequal standards all over the place, but a few, like antiretroviral (ARV) availability to treat HIV/AIDS, became points of moral action. And like HIV/AIDS, diabetes also shares the market dilemmas of treatment for a lifelong disease that afflicts populations in both high- and low-income countries.

In the famous case of ARVs, alliances of patient advocates and national governments played major roles in using state laboratory capacities to put pressure on industrial players and make proprietary life-sustaining treatments more affordable. When it comes to diabetes hardware, a number of innovative projects (Akpan 2015) to design glucose management for people living in low-income settings are starting to get off the ground. One such effort is under way at the MIT Little Devices Lab (http://littledevices.mit.edu/), where I visited to learn more about work on “open design” by Jose Gomez-Marquez and his team. Studying the circuits of various glucose meters to figure out how they are wired, they envision an open device that could be useful for practitioners in his home country of Honduras or key collaborators in Nicaragua, for example, or a design blueprint that might be published online as a template for consideration by national laboratories in countries like Brazil that have the capacity to engineer their own quality components. The Little Devices team has also begun exploring what they call “lost technologies” of diabetes care.

Fig. 5. Jose Gomez-Marquez holding an open glucometer prototype at MIT Little Devices Lab (photo by author).

Such efforts are full of techno-ethical challenges, as Gomez-Marquez describes elsewhere (Mayo Clinic 2017). Yet they surely seem worth grappling with, given how uneven global diabetes care looks at present. In Belize at least, health workers I knew did not recommend urine dipstick tests for diabetes home care because they weren’t considered best practice. But the stark reality persisted: poorer patients often had no way at home to test their sugar at all. Once I asked in a local clinic how they dealt with this quandary, and was surprised to find out that this simple alternative glucose test—costing pennies instead of dollars, and requiring no machine—had been right there on the clinic shelves all along. It turned out that the same urine dipsticks used to check for infections measured not only leukocytes, but also a row of other indicators, including nitrates, albumin protein, bilirubin, urobillinogen, pH levels, and—most important for diabetics—glucose and ketones, present in urine only when the body is off balance. There were numerous cardboard boxes filled with urine test strip jars in storage, a visiting nurse added; it was one of the few things they kept easily in stock. She invited me to look. “Intended for use in the U.S.A.,” read the bottle’s evasive label.

I twisted off the plastic lid and examined its contents, but they yielded no easy answers either—just little strips of rainbow colored patches, paper bands expiring in a jar.

Fig. 6. A jar of urine test strips that include glucose and ketone indicators (photo by author).

References

Akpan, Nsikan. 2015. “Weavers Turn Silk into Diabetes Test Strips.” NPR, January 8. Available at link.

Akrich, Madeline. 1992. “The De-Scription of Technical Objects.” In Shaping Technology/Building Society: Studies in Sociotechnical Change, edited by W. L. Bijker, pp. 205–224. Cambridge, MA: MIT Press.

Benjamin, Ruha. 2015. “From Park Bench to Lab Bench: What Kind of Future Are We Designing?” [Video]. Available at link.

Clarke, S. F., and J. R. Foster. 2012. “A History of Blood Glucose Meters and Their Role in Self-Monitoring of Diabetes Mellitus.” British Journal of Biomedical Science 69(2):83–93.

Fidler, David. 2008. “A Theory of Open-Source Anarchy.” Indiana Journal of Global Legal Studies 15(1). Available at link.

Grondahl, Paul. 2012. “Growing Diabetic Population Fuels a Black Market.” Albany Times Union, January 30. Available at link.

International Diabetes Federation (IDF). 2015. “IDF Diabetes Atlas, 7^th Edition.” Available at link.

———. 2005. “The Role of Urine Glucose Monitoring in Diabetes: A Valuable Technology in Appropriate Settings.” IDF Position Statement. Brussels, Belgium.

Mayo Clinic. 2017. “Jose Gomez-Marquez.” Transform Conference 2017. Available at link.

Mendosa, David. 2000. “Meter Memories.” Diabetes Wellness Letter, pp. 1–6.

Mol, Annemarie and John Law. 2004. “Embodied Action, Enacted Bodies: The Example of Hypoglycaemia.” Body & Society 10(2-3): 43-62.

Moran-Thomas, Amy. 2016. “Breakthroughs for Whom? Global Diabetes Care and Equitable Design.” New England Journal of Medicine 375: 2317-2319. Available at link.

Redfield, Peter. 2012a. “The Unbearable Lightness of Expats: Double Binds of Humanitarian Mobility.” Cultural Anthropology 27(2):358–382. Available at link.

———. 2012b. “Bioexpectations: Life Technologies as Humanitarian Goods.” Public Culture 24(166):157–184.

Yoo, E.-H., and S.-Y. Lee. 2010. “Glucose Biosensors: An Overview of Use in Clinical Practice.” Sensors (Basel) 10(5):4558–4576.

Notes

[1] This is a gloss of one biosensor technique, described in lay terms to the best of my understanding, but various meters use many different variations of this technology that involve much further nuance. For detailed technical specifics of glucose biosensor technology, see “Glucose Biosensors” (Yoo and Lee 2010).

[2] Mapping the “global burden” of diabetes is very unevenly underway, as these statistics begin to suggest. Laboratory tests (such as fasting blood glucose or A1Cs) are more accurate to determine if someone has diabetes, since they provide a picture of glucose beyond the particular moment of testing. But these are much more logistically difficult than glucometer checks to realize outside clinics. Institutions currently rely on a patchwork of differently collected and missing data to estimate their diabetes projections, projects that raise their own conundrums (see IDF 2015).

[3] HLN News Now, CNN International Television; 7 June 2012.

[4] Though trimmed for space here, elsewhere this project unfolds in close dialogue with many other ethnographic and historical projects that also consider about how diabetic conditions are socially framed and materially enacted across distinct global contexts.

Featured Image: Foil inside an opened glucometer strip (photo by author).

The mobile phone revolution in Papua New Guinea (PNG) began in July 2007 when Irish billionaire Denis O’Brien’s company Digicel, in response to the government’s liberalization of the tele-communications sector, began rolling out its wireless network. Digicel was warmly welcomed by a country whose citizens felt neglected—if not downright mistreated—by the erstwhile state-owned monopoly Telikom due to the prohibitively expensive and geographically limited wireless services of its subsidiary Bemobile. Digicel did not disavow nationalism, to which Telikom reactively appealed, and also apparently cared about PNG, sponsoring sports teams and cultural festivals.

Digicel billboard in Goroka, Eastern Highlands Province, Papua New Guinea, 2015. Photo by D. Doiki

Most important, Digicel delivered wireless service to areas where it was never before available (Fig. 1), thus making good on its promise to bring the nation together (Fig. 2).

Individual customer benefits mattered too. Digicel quickly put basic handsets such as the Nokia 1020 within affordable reach of tens of thousands of people, many living in remote rural areas. By virtue of small, prepaid purchases of airtime, villagers could for the first time experience long-distance communication, especially with kin living and working in urban centers. And when a customer had no credit on her phone, she could use the free “call me” short-message service (SMS) to request that a loved one get in touch (Fig. 3). Digicel clearly understood the value of mobile phones as affective technologies, objects that “mediate the expression, display, experience and communication of feelings and emotions” (Lasen 2004:1).

Fig. 1. (left) Digicel newspaper ad, September 2007. Photo by R. Foster
Fig. 2. (right) Digicel ad, circa 2011.

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In the beginning, people did not have many numbers to call or much credit with which to call. So they called Customer Care. Dial 123. 24/7. Free. They still call. But now there is a charge for calling during off-peak hours. The charge is meant to discourage prank calls, especially late at night.

Fig. 3. Digicel ad for “call me” sms service,
circa 2007.

People also called numbers randomly in search of phone friends who might become romantically involved and eventually meet face to face. Persistent calls from unknown numbers became a common topic of public conversation and a compelling justification for legislating mandatory registration of subscriber identity modules (SIM cards), which finally happened in 2016.

Mobile phones entrained new possibilities not only for sustaining long-distance kin relations but also for experimenting with self-development. The capacity to engage in novel forms of intimacy with strangers and in private forms of communications with intimates was welcomed by some, decried by others, and regarded with ambivalence by most people. New ways to express care and concern—such as sending and receiving credit requests for airtime—were offered by a company that promoted itself as a caregiver to its customers and to the nation as a whole.

At the same time, mobile phones, understood as social and material assemblages that include more than the discrete handset, were taken up in ways that exposed the premises of a robust moral economy: what companies, consumers and state agents owed to each other posed a perpetually open question. The capacity of the PNG state to regulate Digicel, which owns and controls the network it built, is weak; the business challenge faced by Digicel to overcome the absence of a reliable electric power grid and the chronic insecurity of corporate assets such as cell towers, which are regularly vandalized, is enormous; and the ability of consumers to use the network in the face of limited financial means and increasing demand for smartphones and data is always under threat.

In short, the moral economy of customer care in PNG is precarious for everyone. Here I offer five brief ethnographic examples.

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Karen acquired her first mobile phone when she came to university in the capital city of Port Moresby in 2011. She already had friends who owned mobile phones despite an official ban on the devices at her high school. But at university, every student seemed to have not just a phone, but a smartphone that enabled use of the internet for their studies. Having a phone appeared to be a standard expectation, and students who did not have them felt an acute sense of being left out. Karen’s uncle gave her an old Samsung model that he brought from Australia, which she used until the inconvenience of not having a matching charger for the phone compelled her to buy a new entry-level Alcatel smartphone for 149 kina (approximately US$50; Fig. 4).

Fig. 4. Entry-level smartphone on display
at Digicel retail outlet, 2014.
Photo by R. Foster.

For Karen, the phone was helpful in overcoming her nervousness about approaching her lecturers and tutors in person. She would instead call them and pay attention to how they conversed and asked her questions: “How may I help you?” Karen learned and repeated her lecturer’s conversational strategies in her face-to-face interactions with others, developing a sense of confidence and clarity in her public speaking. “I learned how to approach people…. I felt like my life changed.”

The phone allowed Karen to overcome her timidity (and she has witnessed similar transformations in other female university students). For example, Karen now has no hesitation about calling Digicel’s Customer Care when she has questions about the accuracy with which her prepaid balance of airtime is being managed. Dial 123, send: “How may I help you?” Digicel will find the right person to attend to her concern. The next time Karen makes a call, she will be charged at a lower rate. She is not sure how it works exactly. But they respond. “They respond…because I am their customer.” As a customer, Karen received the sort of recognition that many Papua New Guineans seek in vain from a state that has failed since independence in 1975 to bring development to its citizens in the form of tangible goods and services.

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Not all Digicel customers agree with Karen. The evidence is found on the Facebook page of the Digicel Complaints Group, a public forum for more than 43,000 mobile phone users. Group members who purchase airtime from Digicel, the dominant mobile network operator, use the forum to register dissatisfaction with the company’s services. They express particular concern about the conversion of prepaid airtime into data and the dubious ways in which Digicel adds and subtracts data from an individual’s balance. Complaints often concern the failure of credits to appear on a person’s phone after a purchase has been made or the disappearance of data from a person’s balance even when the phone is not in use.

My friend Cletus’s complaint to the group is fairly typical:

At exactly 11am today, I entered two K5 flex numbers: 01 7249 490 5910 & 16 2662 659 3637. At exactly 11:14am, Digicel sent me two messages: 1. Advised that I have used up my data and 2. Asked whether I need airtime of K13 advance. I immediately checked my balance only to see K5.03. I texted Digicel and 5 minutes [later] I was reimbursed K3 and not the whole K4.77. What a daylight robbery!

People sometimes post screenshots of the balances on their phones as evidence of stolen data. Accusations of robbery and theft, of being “ripped” (off), are commonplace. Such complaints recall historian E. P. Thompson’s (1971) well-known account of the protests that erupted as a moral economy of food provision gave way to practices and principles associated with “free trade” in 18th-century England. These protests, which often led to direct action, invoked notions of fair and transparent dealing in the face of concerns that the poor suffered at the hands of those with “command of a prime necessity of life”  (Thompson 1971:93). Much like the folks about whom Thompson wrote, Digicel Complaints Group members express intense feelings over “weights and measures” and beseech the authorities to regulate business transactions. In other words, offended consumers look for help from the same neglectful state that let them down before Digicel arrived.

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The capacity of poor people to own and operate a phone in the developing world hinges on technologies of prepay, which allow users to pay as they go by buying small amounts of airtime when necessary or when funds become irregularly available. Managing one’s airtime requires tempering the practice of self-discipline with responsiveness to the obligations of caring for others.

Winnie is a heavy user who can spend up to 100 kina (US$33) a week in airtime credits. She is a young single woman living far from home and regards frequent communication with her family and friends as nothing less than essential. Winnie has a steady income and is generous when her kin send credit requests for airtime, which she can transfer directly to their phones for a small fee. She says that she is capable of spending all her savings on airtime, and she has on occasion come close to doing so by “topping up” her phone through a mobile banking account, a relatively new service that effectively enables users to purchase airtime anytime, anywhere. (A fair comparison is with gambling machines that provide access to a player’s bank account without requiring the player to leave his or her seat in front of the machine.) To discipline herself—and she used the English word discipline—Winnie has opened an account with another bank into which she makes weekly deposits. This bank, Winnie explained, does not offer the mobile top-up service. She has thus safeguarded her money from herself (see Foster, in press).

Winnie is explicit about the calculations that she makes in managing her mobile phone. She says that she does not feel able to start the day unless she is equipped to communicate. So, in the morning she will top up her phone for 5 kina (US$1.66). This top-up gives her 100 free promotional minutes for use between 11pm that night and 7am the following morning. She then purchases a one-day data pass: 60 MB for 3 kina. This data is enough to allow her to go online and communicate with friends and family via the applications WhatsApp and Viber. Winnie discovered that she could send voice messages over the internet for much less money than making voice calls. Finally, Winnie purchases a discounted bundle of 60 text messages for 1.20 kina. She will use most if not all of these text messages before they expire at midnight. That leaves 80 toea as a balance in case Winnie needs to make a quick phone call during the day (100 toea = 1 kina). (On-net calls from one Digicel phone to another are billed at 79 toea per minute, with per-second billing, during the peak hours of 7am to 9pm.) Once she has made these preparations, Winnie feels ready to go out into the world and meet the demands of the day.

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Winnie’s daily routine might understandably lead one to conclude that a peculiar kind of calculative rationality has been baked into the phone itself, such that Lucy’s habit of giving gifts to her relatives is subsumed within the sort of measuring and monitoring associated with markets and commodity exchange. This same tension between alternative logics of gift and commodity shapes the larger social and material assemblage of which the phone itself is part. It is a tension that threatens the future of customer care.

Fig 5. Phone repair vendor’s table, Goroka, 2015. Photo by W. Magea

Matthew, a single man in his early thirties, repairs mobile phones and sells airtime at a street stand in the highlands town of Goroka (Fig. 5). He occupies a particular spot on a particular corner with other vendors who sell cigarettes, betel nuts, hard-boiled eggs, soft drinks, and the scratch (or “flex”) cards that people buy to top up their mobile phone airtime balances (Fig. 6). Matthew was one of the first to teach himself how to repair phones; he and his friend and workmate Gabriel were also among the first to start selling airtime in 2009 as Digicel expanded its network of cell towers across the country.

Fig. 6. Street vendor selling scratch or “flex” cards, Goroka, 2015. Photo by W. Magea

Matthew regards his work as a service to the community; indeed, to the nation. His business yields to the demands of a moral economy that Thompson would easily recognize. Villagers who come to town with no money can offer their homegrown bananas or sweet potatoes in exchange for repair services. Town workers, however, will be sized up and charged according to Matthew’s estimate of their ability to pay. The vendors, moreover, care for each other: they all offer their goods at the same price and eschew overt competition. One vendor’s business crashed when he overspent his revenue and was unable to purchase a new supply of scratch cards. A fellow vendor hired him until he was able, a year later, to save enough money to re-establish his own business.

Matthew insists that he and his fellow vendors are part of Digicel: without them the network would not work. His recognition of people as infrastructure is entirely plausible; Digicel still relies on vendors in places like Goroka to distribute airtime credit into the hinterlands where people prefer to buy scratch cards in town for use (or resale) later in the village. In cities like Port Moresby, however, the advent of smartphones has enabled more and more people to top up directly online, buying airtime like Winnie through linked banking accounts. Moreover, new forms of “self-care”—quite different from the kind of care that Matthew affords his customer—are being promoted. In January 2017, Digicel launched the My Digicel App for smartphone users, promising customers an efficient tool for “managing their Digicel life” (The National 2017). Several months later, the company introduced a menu that would allow customers, including users of basic handsets, to assist themselves with queries relating to data and top up, among other things. Dial *123#. 24/7. Free. A list of frequently asked questions appears on the phone’s screen.

The future of the prepaid scratch card is dubious, and the economic niche of street vendors is shrinking. There is a policy argument to be made that preservation of the scratch card vendors’ livelihood would support the so-called informal economy on which so many Papua New Guineans depend. For Matthew, however, it is an ethical as well as economic question: Does Digicel really care about him and his fellow vendors, who were present at the beginning when the company was first establishing itself in the country? His concerns echo those of the Digicel Complaints Group, and pose the unsettling question of whether Digicel still cares for the people of PNG 10 years after the company brought them a revolution in communications.

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Digicel of course expresses care and concern in ways that are familiar to corporate observers, if not immediately relevant to Matthew. The company has set up a branch of the Digicel Foundation in PNG as a way of giving back to the community by funding health and education projects—providing bits of infrastructure that the state has not—like a reliable nationwide telecommunications system. The company has even addressed one of the main problems for individuals in operating a mobile phone, namely keeping the battery charged. Outside of urban centers, which experience frequent power outages, access to electricity is severely restricted. Digicel has responded by marketing small solar panels for 95 kina (US$31; Fig. 7).

Fig. 7. Digicel ad for solar panel
at Jackson’s Airport, Port Moresby, 2016.
Photo by R. Foster

The Digicel Foundation attracts the standard critiques of corporate social responsibility: it’s window dressing and public relations and so on. Whether the Digicel Foundation is successful in promoting goodwill and positive sentiments among the people of PNG is unclear. The uptake of mobile phones in the country, however, continually surprises with respect to the capacity of these devices as affective technologies. My final ethnographic example underscores the high stakes involved in the emergence of a desirable new form of affective technology over which one’s control is exceedingly tenuous.

Lucy is in her early fifties, a rural woman with little education who, after being diagnosed as HIV positive, was struggling to live on her own after her older brother had refused to take her in.[1] A previous husband offered Lucy some money and a used mobile phone. Desperate, hungry, and contemplating suicide, Lucy began calling the contacts saved in the phone until one woman, instead of yelling and hanging up, agreed to speak with her. This woman, Angela, responded with compassion and began sending Lucy small gifts of food, money, and secondhand clothes. Lucy and Angela never met, but continued to talk by phone, thereby restoring Lucy’s feelings of hope and alleviating the anxieties that Lucy thought would reduce the effectiveness of her anti-retroviral medications. A friend found by chance on a random call enabled Lucy’s old mobile phone to function therapeutically as an affective technology, a medium for giving and receiving care.

Lucy’s story, like Matthew’s, exposes not only the possibilities but also the vulnerabilities inherent in the shifting moral economy of mobile phones. But Lucy’s story does not end well. Her phone, the source of Lucy’s emotional sustenance, was eventually stolen: “All those phone friends, in Port Moresby, Mt. Hagen, and other places, they would send me credit, and we talked all the time, every night, and now I don’t have a phone, and I’ve lost all those numbers. It’s terrible. I can’t stop crying about it. I had the same phone for four years, and had so many numbers, so many friends. And now it’s all gone.”

Acknowledgments

In this essay I draw on research supported by the Australian Research Council through a grant (DP140103773) awarded to Professor Heather Horst (University of Sydney/RMIT University) and the author. Wendy Bai Magea offered helpful research assistance.

References

Foster, Robert J. In press. “Top-Up: The Moral Economy of Prepaid Mobile Phone Subscriptions.” In The Moral Economy of Mobile Phones: Pacific Islands Perspectives, edited by R. Foster and H. Horst. Canberra, Australia: ANU Press.

Lasen, Amparo. 2004. “Affective Technologies—Emotions and Mobile Phones.” Vodafone Receiver Magazine 11. Available at link.

The National. 2017. “Digicel PNG Launches My Digicel Application.” The National, January 20. Available at link.

Thompson, E. P. 1971. “The Moral Economy of the English Crowd in the Eighteenth Century.” Past and Present 50:71–136.

Wardlow, Holly. In press. “HIV, Phone Friends, and Affective Technology in Papua New Guinea.” In The Moral Economy of Mobile Phones: Pacific Islands Perspectives, edited by R. Foster and H. Horst. Canberra, Australia: ANU Press.

[1] Lucy’s story is told more fully in Wardlow (in press).

Featured Photo: Digicel Flex Cards. Photo by M. Boie.

“Little Development Devices/Humanitarian Goods” seeks to explore objects or instruments designed to care about and improve the welfare of infrastructurally marginal populations (i.e. those lacking connection to “networked” forms of modern provisioning—such as water, sewerage, communication, electricity—or to services such as health care and finance). As our title suggests, we perceive two trajectories into this phenomenon.

The first derives from the legacy of the large, capital intensive and spatially fixed infrastructural projects of post-World War II development — such as dams, power plants, and road networks — which embody a substantive vision of societal transformation as laid out and organized by technocratic experts and government officials who act in the name, and for the benefit, of a whole nation. In contrast, the devices we highlight arose against the backdrop of sustained and polymorphous critiques of this older paradigm of development. They combine elements of earlier attempts to define more “appropriate” technology with new techniques for monitoring, calculation and testing. In reacting to perceptions of past failure, their normative rationality is oriented to immediate, measurable and testable outcomes.

The second trajectory stems from the parallel emergence of humanitarianism as a mode and set of techniques for crisis response, including the establishment of intergovernmental agencies and nongovernmental organizations devoted to the care of distant others, as well as the standardization of associated mobile technologies like refugee camps. The devices we examine here respond to perceived incapacities, failures and perverse outcomes of this very aid regime, even while seeking to further its general goals of alleviating pressing needs and saving lives. Many rely on market logic and present themselves as commodities more than gifts, ostensibly enrolling profit motives into the service of a greater good.

In this issue of Limn we seek to ask: What are we to make of the proliferation of such small devices? What do they tell us about the state of “development” and “humanitarianism” as projects? And what do we make of the convergence of humanitarian and developmental projects around them? What forms of life, and what kinds of subjects, do they work on and constitute? What relationships do they establish between expertise, government, and the purported beneficiaries of these devices? What politics do they make possible – or preclude? Do some appear analogous to hacks, exploiting the vulnerability of existing infrastructures for other ends? And what might a critical social science have to say about them?