Jackie Xu and Judy Riviere

March 20, 2017

Global health partnerships are often fraught with donor-recipient power dynamics. In Tanzania, Americans are perceived to have “big money, big personalities, and data obsession.” Fighting against these stereotypes, we strove to build an authentic two-way partnership while working with the SHED Foundation during summer 2016.

Introduction

In 2016, The Lancet published the first systematic analysis of the geographical distribution of university global health partnerships (GHPs). The rising popularity of global health as a field has led universities and NGOs to establish GHPs in developing nations.This partnership model stresses open communication and listening, allowing each partner to voice their needs and eliminate the hierarchical structure present in current global health work. Professor Johnanna Crane of The Lancet notes “true partnership is especially challenging in global health, in which institutions must forge collaborations across sometimes staggering inequalities” (1). In these words lies the main goal of GlobeMed: to overcome global health inequities through effective partnerships.

Currently, GlobeMed at Duke is partnered with the Shirati Health, Education, and Development (SHED) Foundation in Tanzania. During the summer of 2016, we three Duke undergraduates, Jackie, Judy, and Alexa, lived in Shirati for nine weeks, sponsored by a DukeEngage Independent Project grant. As interns for SHED and advocates for GlobeMed at Duke, we worked to strengthen our organizational relationship via three projects: 1) build a school desk carpentry program to promote self-sustainability for SHED, 2) provide schistosomiasis and hygiene education to SHED schoolchildren, and 3) perform project evaluation on the Ministry of Health’s mass drug administration work.

While the foundation of the collaborative global health partnership model is strong in theory, we found that achieving its goals is much easier said than done. Work in the global health field remains plagued by its deep imperialistic past. Too often, donor-driven cultures within non-profit organizations impede meaningful discussions on community needs. Stereotypes about well-to-do foreigners result in prejudices that hinder progress and communication. Such was our experience with SHED, yet through our time engaging with community members, we learned how to overcome these limitations and achieve our project goals.

A New Foundation for Education

Initially, we planned to work on a schistosomiasis mass drug administration (MDA) campaign with SHED. However, a few days before leaving home, we received an email from SHED informing us that the Ministry of Health had initiated a schistosomiasis and worms MDA for all primary schools in the Rorya district of Tanzania, essentially eliminating the need for us to conduct our planned summer work. In the chaos of our 48-hour flight and arrival in Shirati, we scrambled to plan a new project. Throughout our research, we discovered a common theme through stories of global health fieldwork: a lack of school desks in primary schools. Thus, we were catapulted into our newest project.

A lack of school desks in Tanzanian primary schools began when the President of Tanzania, John Magafuli, created a policy for free primary school education. Consequently, school attendance skyrocketed, causing overcrowding in primary schools. To illustrate this issue, television advertisements frequently streamed short films of five to six school children squeezed together on a single bench meant for three. In response, Magafuli spearheaded a school desk construction campaign to provide for the new influx of students, after which, nearly every school within the Mara region had proper desks. Overall, Magafuli’s rapid mobilization of primary schools amazed us, inspiring us to aid in this cause.

The main primary school that we worked with, Shirati Primary, was a two minute walk from our SHED complex. The first time we visited the school, we initially discovered an empty schoolyard. We retreated embarrassed, but not before a few students inside spotted us and whispered to their peers in amazement, “mzungu!”, Swahili for “foreigner!” Suddenly, a river of children dressed in identical uniforms rushed towards us. Despite their excitement, they remained at a distance, forming an invisible circle around us. Following closely, the headmaster walked out to greet us as well. Although we apologized profusely, the headmaster seemed unfazed by our intrusive entry. He promptly gave us a tour of the school, dismissed the children from class, and showed us a classroom filled with broken wooden desks. Dilapidated pieces of wood had been stamped with the phrase “DONATED BY NMB.” The marking signified that these desks had been donated by a Parliamentary member. Shaking his head in contempt, the headmaster explained that the donation was merely a political strategy to increase the Parliament member’s chances of re-election. However, the cheap materials and woodworking had rendered much of the original donation useless. Furthermore, the potholes that riddled the concrete floors of the Shirati Primary classrooms rapidly aged the poorly constructed desks.

Despite our initial belief that the Tanzanian government had truly altruistic motives for providing school desks, we found that most officials only provided desks in hopes that citizens would favor them in the upcoming elections. In this respect, the desk donation reflected a donor-driven culture, one that promotes giving as a means to an end. To combat this issue, we researched how to create the optimal desk design: we aimed to find desks with the highest quality that were able to withstand the uneven floors, but at the lowest cost. GlobeMed at Duke was the sole funder of this project, as SHED lacked its own source of income.

Determined to avoid instances of pseudo-donation and develop a lasting and meaningful product for Shirati Primary, we planned meetings with Shirati Primary to review every grueling detail necessary to construct high-quality desks. For these meetings, our American notions of professionalism included scheduling ahead of time, communicating consistently, and using organizational spreadsheets. Yet we soon found that these notions were inconsistent with Tanzanian culture. In Tanzania, meetings would spontaneously relocate from SHED to Shirati Primary and often were haphazard in organization. At first, we attempted to force the planning process our way, wrongfully exercising our power as the funders. However, we quickly realized that we were reinforcing Tanzanian stereotypes about American donors of “big money, big personalities, and data obsession.” Thus, partnership with SHED required that we adapt to their organizational culture.

Through these meetings, we determined that our main goal was to build the foundations for a carpentry business owned by SHED that could serve as a potential source of income for this non-profit. Thus, our global health summer internship transformed into lessons in wood planing (the process of smoothing wood surfaces) and metal welding. Despite our feelings of disconnect from healthcare, we came to understand the importance of our work as one of the many faces global health work.

Since Shirati Primary is a public school, our work needed to be approved by the government. As such, government officials oversaw the our project. SHED, concerned that these officials would attempt to take credit for the handiwork (funded, researched, and executed by GlobeMed with SHED), encouraged us to paint the words “DONATED BY GLOBEMED/SHED” on the side of the desks. We shied away from this idea, feeling that such a message reinforced ideas of charity as an achievement. Additionally, we dreamt of attracting the attention of the District government as potential customers to expand our impact, which fortunately came true. One day, a District official visited Shirati Primary to see our work in progress, hearing the gossip that mzungus had been working with Shirati Primary on school desks. This small visit ultimately increased the Tanzanian government’s support our project goals, and thus, laid the foundation for future collaborations.

The Challenges of Collaboration

Living in Shirati for 9 weeks endowed us with a new perspective on global health prejudices and donor driven culture. Often, it is easy to criticize Tanzania’s concept of time: it slows processes down, it drags work out, and it is less organized and reliable. Yet incidentally, we discovered the benefits of actually taking time to process and focus, something Americans too often forget to do. During meetings, we always had everyone’s full attention, without any distracting smartphone notifications. Carpenters would stay after meetings to discuss their plans with us, and children voluntarily stayed at school after class to hear more of our lessons. Our previous presumptions about how time should be managed exemplifies the “assumed values” that foreigners bring into global health work. Therefore, global health partners need to adapt to working within the local culture, as opposed to “fixing” their partners, or getting stuck on logistical challenges.

Working closely with a partner organization in an unfamiliar community was, at times, a true challenge. From small complications like a malfunctioning printer to larger issues like absentee taxi drivers, we accumulated an unnerving number of obstacles. However, we realized that pushing against these problems did not resolve them. Rather, we had to understand and adapt to community dynamics and in order to contribute towards the existing work of local organizations like SHED. Working through the partnership model, we strove to dismantle the traditional power dynamic of donor and recipient that often interferes with global health work.

However, in a sense, power dynamics were inevitable. On one hand, we needed SHED’s knowledge of the local community and communication tools to carry out projects, allowing the organization executives to have the final say on major project decisions. On the other hand, we were perceived as “rich” investors by certain Tanzanians. Therefore we were often granted excessive liberty to do whatever we wanted at the primary schools, which in fact made our work more difficult, as the school headmasters avoided expressing their needs clearly. We had to navigate these power dynamics with grace—at times raising our voices, and at others encouraging our partners to take the lead.

Conclusion

SHED played a crucial role in our partnership: they provided essential knowledge, cultural capability, and technical expertise. They knew which of the local carpenters were hard-working and which cheated on business deals. They provided guidance on more minute details such as  the cost of lumber and how much we should compensate carpenters for their work. Our role in the partnership was to provide an outsider perspective to promote the growth of new ideas, such as creating classroom instruction materials or establishing more partnerships between SHED and other local non-profits.

A partnership favors the voices of many. Talking and understanding to meet in the middle is the road to progress. Building respectful and constructive relationships to give a platform for all takes time and cooperation. Global health partnerships present a unique opportunity to revolutionize how we address global health—as an act of listening, deep community engagement, collaboration, and above all, a balance of power to provide a multiperspective approach to service.

References

1. Crane J. Scrambling for Africa? Universities and global health. The Lancet. 2011 Apr 23;377(9775):1388-90.