Point/Counterpoint on Samahope: Leila Janah’s Response

We asked Samahope founder Leila Janah to share her reaction to our criticisms of the organization’s approach, and explain the importance of the work Samahope is doing. We very much appreciate her thoughtful response, and her willingness to acknowledge the difficulty of getting this sort of work right. For more on this debate, check out the Quora discussion on Samahope. Here are Leila’s thoughts:

I founded Samahope after running into a surgeon named Dr. Maggi, a retired Texan OB/GYN, on a trip to Sierra Leone with the State Department last year. I’d visited hoping to find a site for Samasource, but realized quickly that our model wouldn’t work in a country where 70% of the population is illiterate and there is almost no infrastructure. I also learned that one in eight women in Sierra Leone die in childbirth — the worst rate anywhere in the world. There is almost no acute care for mothers in Sierra Leone, and there are 50 surgeons in the entire country.

I realized I could apply my tech background to fixing another problem: raising money for clinics in poor places offering life-saving care to people beyond the reach of public hospitals. My friends at Kiva encouraged me to do this, and I set up samahope.org with two volunteers, Shawn Graft (a web developer) and Shivani Patel (a former McKinsey consultant and product manager).

The aim of the site is to fund life-changing medical treatments for people who can’t afford them.

On your first point, I hear you — we’d love to paint a fuller picture of each person, but we have very little time to gather the patient’s story in the field. If we spent more time doing this, our overhead costs would increase and donors would be less interested in funding surgeries. In the future, we’d love to create a way for patients to share their own stories through a more direct connection to the site, but right now, this is very difficult. Most patients do not have cell phones or speak English, and many do not speak the lingua franca of their country, so an in-person visit with multiple levels of translation is required to capture their stories.

With regard to the issue of possible coerced disclosure: Samahope actually works as a reimbursement method for partners who perform surgeries. Most partners offering these types of surgeries require any patient who receives a procedure to allow use of his or her photo and bio — this is true for the best-rated organization in this field, ReSurge (formerly Interplast; here’s a review on GiveWell). In an ideal world, surgeries would be funded through public health systems and no one would have to disclose personal information. In the real world, disclosure is necessary to both prevent fraud and prove that the operation was completed, and to raise money.

Exceptions are made if disclosure would compromise the safety of a patient.

Two other points are worth noting here: (1) Most patients who suffer from fistula or the most common conditions requiring reconstructive surgery are already stigmatized; and (2) When I interviewed 14 patients personally in August 2012, I found that most women wanted to share their condition to raise awareness and ensure that other women with fistulas would come forward.

As for your concern that the setup forces the potential recipients into competition, this is true, and it sucks. We don’t know how to solve for the fact that every person on the site is in need, and there is not a good way to distinguish each patient. One idea we had is to introduce a button to allow users to let Samahope allocate their donation (most likely we will choose the profile that has been on the site the longest, or to complete funding for a patient with a small amount remaining).

As we add more treatments or surgery types (for example, burn or cleft palate repair), this problem will get worse: how to choose among so many people with so much need? That said, this is a problem that every donor faces every time he or she gives, as there are billions of needy people who could all benefit from a gift. So in the worst case Samahope is transferring an existing problem that already exists in the field of giving to the web, but I don’t think we’re creating new problems.

Finally, I’ve heard arguments both for and against representing younger people on the site. I use the term “younger people” and not “underage” because there is little consensus as to what constitutes underage globally. Another complicating factor is that many of the young women on Samahope do not know their own ages or have any public record of their birth (I witnessed this personally in my recent visit to Sierra Leone).

For:

  • Treating someone younger results in more benefit, as more years of his or her life will be lived in better health. Public health experts and economists think in terms of “Quality-Adjusted Life-Years” — in other words, the number of years of life a person lives times the quality of that life (with a discount for medical conditions that make a person live sub-optimally). In QALYs, a young person receives more benefit than an older person from a given surgery, since she has more life to live.
  • Young people heal faster, and may be more likely to receive a positive result from surgery.
  • Young people are disproportionately affected by certain conditions for which reconstructive surgery is effective, such as burns and cleft palate. According to the World Health Organization, the vast majority (95%) of burn victims are in developing countries, and burns are in the top 15 causes of death for people aged 5-29.

Against:

  • Young people are more vulnerable to exploitation and abuse if their information is made public without adequate protection.
  • Young people may not fully understand the implications of publicizing their patient information, and may not be able to provide legal, informed consent.
  • Child safety laws in some countries prohibit the display or collection of children’s information below a certain age (in the US, this is 13).

Bottom line: this is a very tough issue. I’ve had knee-jerk reactions to sites like Samahope in the past whenever they portray poor people as helpless victims and somehow different from you and me. But after spending ten years going back and forth to Africa and Asia and meeting a lot more people who can’t afford the basic necessities of life, I’ve found that the people portrayed on those sites don’t mind sharing their stories if that gives them access to the things they need. The magnitude of this problem is so great, and the amount of money spent to fix it so comparatively tiny, that the right thing to do is to try to raise more funds and direct them to the right clinics, even if our methods aren’t perfect.

Point/Counterpoint on Samahope: Our Two Cents

As promised, here are our thoughts on Samahope’s use of patient profiles to raise money for fistula repair in Sierra Leone:

Although we’re kind of in love with the idea of a Kickstarter for poor women’s vaginas, we’re concerned about the fact that these women are presented primarily in terms of their injury. The key information provided for potential donors browsing through the photographs of possible recipients is “name, age, nature of fistula.” Some of the profiles list a few of the women’s hobbies or interests (“gardening” is a popular choice), but the bulk of the information is fistula-related.

We’re also troubled by the coercive dynamic implicit in the offer of assistance in exchange for public admission of a stigmatizing injury. Even in the best-case scenario, in which the women have no shame about their injuries and aren’t worried about stigma, Samahope is asking women to publicly reveal private information in exchange for help. Leila points out that she has personally spoken with fourteen of the women, and they were all willing to share their stories, but we suspect we’d also be “willing” to publicize our gynecological issues if it meant we would get otherwise unaffordable much-needed treatment. If ladies who aren’t willing to disclose their condition to the global public aren’t eligible for funded surgeries (as Leila’s comments suggest that they’re aren’t), this whole process starts to seem pretty coercive.

Here in the U.S., we don’t think it’s acceptable to force women to publicly describe their vaginas in exchange for vagina-related assistance: We’d never accept it if, say, Medicaid were to require women to post their names, photos, and description of their gynecological problems on a website in order to visit an OB/GYN.  That policy might find a fan in Rush Limbaugh, who famously said that he should be allowed to view the sex acts of young women who received government-subsidized birth control, but that’s hardly indicative of mainstream morality; his comments were (rightly) greeted with horror by the general public.

Both of these concerns (the reduction of a person to an injury, and the potentially coercive nature of the requirement to reveal private medical info) are heightened in the case of the underage girls on the site. We propose that when the question is: “hey, should i post this photo of a 14 year old girl, along with her name, and a description of her broken vagina?” the answer should always be “no.”

Finally, we worry that the setup of the appeal for help – presenting the women and girls almost as if they’re in competition for funding – sets up a disturbing decision process for the potential donor who must choose the most “worthy” (damaged? youngest? prettiest?) recipient for their funds. This mirrors a broader trend that disturbs us, in which NGOs compete for funding and attention by jostling to show the most pathetic victims possible. (Not just a starving woman, but a starving woman who has been raped.  Not just a starving woman who has been raped, but a starving child who has been raped. Not just a starving child who has been raped, but a starving child who has been trafficked into sexual slavery…)  This not only sets up a weird competition for who is “most deserving” or “most in need,” it also contributes to a culture in which no information is too private, and no depiction too demeaning, to demand of victims.

We are not cool with an NGO culture that focuses more on gratifying the egos of donors than on preserving the dignity of recipients. Campaigns like this one contribute to that culture, regardless of their intentions.

None of this is to say that we don’t think Samahope should raise money for fistula repair in Sierra Leone. We’re fully on board with soliciting wealthy Americans for money for poor African women’s vaginas. And actually, we think this has a lot of potential as the next great hipster cause. Think about it: hipsters LOVE to say the word “vagina.” (Look at us, for instance.) And West Africa Fistula Foundation, which performs the Samahope-funded surgeries, seems like a worthy beneficiary. Their focus on recruiting and training local staff is particularly encouraging.

We think there are some pretty easy fixes for the problems we’ve identified above. Nixing the photos of the underage girls would be a great start. We also challenge Samasource to consider whether they could raise money effectively for fistula repair without running photos of pre-operative patients at all. We understand the urge to present real people in need of immediate help – we’ve all seen the research showing that individuals are much more inclined to give when they have a particular person with whom to associate the need for donations. But we think creatively presented profiles (yes, and photos too) of post-op patients would be a more ethical way to establish this connection. Although it would definitely forego some of the urgency of the appeal, showing women who are able to live full, healthy lives as a result of fistula repair would be a moving testament to the value of Samahope’s work, and would clearly underscore the need to fund help for similarly situated women.

Stay tuned for Samahope founder Leila Janah’s response later on…

Let’s Get Ready to Rumble

Our initial reaction when we first saw Samahope was: Man, what brilliant satire. It so perfectly skewers the particular sort of poverty porn-y, competitive victimhood-encouraging NGO that we’re always ranting about. But as we clicked through the site, which posts pictures of Sierra Leonean women and girls suffering from fistula and asks for donations to pay for surgical intervention, we began to get that uncomfortable tingling that accompanies the realization that something you thought was a hilarious send-up of a disturbing phenomenon is actually just one more example of the disturbing phenomenon itself. (What? It’s a real feeling. We get it all the time.)

We didn’t want to jump to any conclusions, though, because Samahope is backed by Leila Janah, the founder of Samasource, which is “an innovative social business that connects women and youth living in poverty to dignified work via the internet” that we’ve been fans of for years. But when we reached out to Leila on Twitter, she told us that Samahope is totally for reals. We mentioned that we were having a lot of uncomfortable, squicked-out feelings about the whole “repair a broken vagina for just $3 a day” approach and that we were going to blog about them (because that’s why people have blogs), and offered Leila the chance to share her perspective as well.

So tomorrow Wednesday we’re going to have an Onion-style Point/Counterpoint in which we’ll explain why this hurts our brains, and Leila will explain why Samahope is doing important and necessary work. Hopefully we’ll all learn and grow.

Things I Liked Quite a Bit: War Don Don

If you’re in New York this week, or DC next week, I highly recommend checking out War Don Don, a new documentary about former RUF leader Issa Sesay’s trial in the Special Court for Sierra Leone.

Director Rebecca Richman Cohen has a J.D. from Harvard law school, and she puts her legal knowledge to good use in this film. Rather than pushing a particular narrative, or view of the international justice system, War Don Don allows the individuals at the heart of the trial to speak for themselves. This leads to some unintentionally funny results at times – at one point prosecutor David Crane (who has since further distinguished himself by becoming an advisor to that ridiculous “to catch a war criminal” show) looks into the camera and says, in an ominous tone, that Sesay’s trial was “the first time I looked into the eyes of a human being and realized that he had no soul.” By contrast, defense attorney Wayne Jordash is prone to wistful sighs about how nice a guy Sesay is, and how he wishes that he weren’t in prison so that they could hang out more.

Amidst the amusing soundbites, however, War Don Don manages to highlight some serious issues with the way the tribunal has administered justice. For instance, although both sides offered payments to witnesses to cover the costs associated with their testimony, the prosecution was able to pay far more than the defense, as well as to offer perks like resettlement in a wealthy country. More troubling still, Sesay receives little credit for his efforts at resolving the war: he was the RUF commander who presided over the disarmament process, a task which he undertook over the objections of much of the RUF’s senior leadership. In a statement delivered to the court during the sentencing phase of his trial, Sesay pointed out that rebels who had refused to disarm were being courted by the UN, while he – who had actively participated in the peace process years earlier – was now in the dock.

To the film’s credit, it doesn’t feel forced to answer the questions it raises. War Don Don is a way to start a broader conversation about international justice, not to end one.

In sum: go, and take your interns with you! War Don Don is showing today at 2 PM and Wednesday the 16th at 4 PM here in New York, as part of the Human Rights Watch International Film Festival, and then on June 22nd and 26th in Silver Spring, as part of the AFI-Discovery Channel Silverdocs Documentary Festival.

Taylor Defense Team in the House

As you may have heard from someone who is more diligent about their blogging than I am, Charles Taylor’s defense opened in The Hague yesterday. (For a refresher on the trial check out Human Rights USA’s handy backgrounder, and for up-to-the-minute news on what’s happening in the courtroom OSJI’s got it covered.)

In his opening statement, lead lawyer Courtenay Griffiths compared Taylor’s extradition to the Netherlands to the slave trade’s forced movement of Africans to Europe. (Because sometimes the race card just isn’t enough and you’ve got to play the whole deck.)

Things only got awesomer when Taylor took off his sunglasses and took the stand himself today, calling the prosecution malicious and pointing to his 14 children as evidence of his “love for humanity.” Ahem.

Former Taylor defense intern / Wronging-Rights-intrepid-girl-special-correspondent Jessica Feinstein notes that although the defense’s move to portray the prosecution as “extending the legacy of colonialism” may seem bizarre to Westerners, it is likely to play well to its target audience. She explains:

“Will some of the things Courtenay said alienate Americans and other Westerners? Very probably. Is that the audience he is trying to reach? No. The things he said ring true to a lot of West Africans, and that is the constituency which this court purportedly seeks to influence.”

So it looks like we can expect a whole bunch more showboating in the days ahead. Yay! If you want to join in the fun, check out the live feed of the trial here.

*Photo of Taylor from the Special Court for Sierra Leone’s website

In Which We Learn Something New About Penises

In our daily read of the entire internet, we came across this report in Sierra Leonean government mouthpiece We Yone. It details an investigation into alleged rapes by security forces during a disturbance at the opposition Sierra Leone People’s Party headquarters in March.

The author concludes that the allegations are fabrications, aimed at discrediting the government. He adds that the purported victims were most likely commercial sex workers (who, as we all know, are unrapeable) because “the opposition HQ is usually transformed into a brothel at night.”

We don’t know much about domestic politics or brothel management in Sierra Leone, but it sounds a little sketchy, right? Well, wait till you get to the medical examiner’s conclusion that the women could not have been raped because they had underwear on. He told the paper: “It was then I began to doubt the veracity of their allegation since it is impossible for a woman to be raped without having her underwear torn apart.” That’s some Poirot-quality deductive reasoning right there.

Apparently, the government got some pushback on this one, because they felt compelled to publish a followup, awesomely titled: “We Meant No Harm to Womanhood and Reaffirm That Alleged Rape Is a Mere Fabrication.” Guess what? They didn’t mean to offend Sierra Leonean women, they’re just dead sure no one was raped during the fracas. How can they be sure, you ask? Easy:

“Under normal circumstance nature prevents the male penis from erecting when the individual is under threat or acting in a commotion. Even during war time incidents of rape occur when all is calm and quite and not when the battle in raging [sic].”

So to sum up, the government apparently feels that its best defense against rape allegations is “Penises are afraid of loud noises.”

Anyone got any more info on this one? (Um, on the Sierra Leone situation, not the other thing.)

International Criminal Law Roundup

It’s been a while since we’ve had one of these, so here’s the news from the tribunals:

  • ICTY: Remember last month when Radovan Karadžić argued that he couldn’t be tried because U.S. negotiator Richard Holbrooke offered him immunity as part of the peace deal, and then U.S. diplomats were like “oh yeah, that totally happened“? (Holbrooke continues to deny it.) Well, yesterday the Appeals Chamber came back with a resounding “nobody cares.” Sorry, dude.
  • ICC: Bashir says international community can stop fretting, he’ll sort out this Darfur war crimes business himself. His own name probably won’t be appearing on any indictee lists, though.
  • Special Court for Sierra Leone: Earlier today the SCSL handed down sentences of 52, 39, and 25 years prison time in the cases (respectively) of RUF leaders Issa Hassan Sesay, Morris Kallon and Augustine Gbao. Last month the three were found guilty on a variety of counts, including the new and exciting forced marriage charge. Also, Charles Taylor’s defense lawyers opened their case on Monday by filing a motion for acquittal, claiming that the prosecution did not present evidence linking Taylor to the planning or execution of the alleged crimes. If the motion succeeds, the prosecutors and their 91 person witness list are going to have some serious explaining to do…
  • Khmer Rouge Tribunal: It’s business as usual over in Cambodia where accusations have surfaced that local staff members were forced to pay kickbacks to the government in order to get their Tribunal jobs. (Totally out of character for the Cambodian government, right?) Meanwhile, apologetic former S-21 prison boss Duch has been testifying up a storm since he took the witness stand last week.
  • Bangladesh: United Nations legal experts will assist the Bangladeshi government with trials of those accused of war crimes during the 1971 independence struggle.
  • Peru: Oh, and getting back to our extrajudicial killings theme, Peru’s Supreme Court found former president Alberto Fujimori guilty of authorizing death squad murders and kidnappings in 1991-1992. Fujimori’s daughter Keiko, a candidate in the 2011 presidential election, promises to pardon him if elected. (Aww…)

While We Wait…

As long as we’re all waiting with bated breath for this afternoon’s (or this morning’s, if you’re in the U.S.) ICC press conference revealing Pre-Trial I’s decision on the Bashir warrant, I thought I’d do a quick update on what else has been going on in the wonderful world of international criminal law.

  • From the Khmer Rouge Tribunal: The Phnom Penh Post reports that the Office of the Co-Investigating Judges (OCIJ) has ordered Ieng Sary’s defense team to take down its website, which the OCIJ alleges contains confidential material. Lawyers for Ieng and other defendants have countered that the Tribunal is needlessly secretive, failing in its obligation to keep the public informed, and that the posted documents weren’t confidential anyway. (Given that the Tribunal’s website has been down the last several times I’ve tried to access it, I feel like there may be some truth to those charges.) In other news from the KRT, last week Ieng Sary’s wife, Ieng Thirith, threw a fit and cursed the Tribunal, and earlier this week Judge Kong Srim announced that there are no funds available to pay local staff salaries this month. So it sounds like things are going well there.
  • From the ICTY: Yesterday Radovan Karadžić refused to plead to the prosecution’s once-again amended indictment (third time’s the charm guys!); an automatic not-guilty plea was (again) entered on his behalf. It’s nice that he seems to be settling into a routine, isn’t it? Oh, and former Serbian President Milan Milutinovic was found not guilty of war crimes and crimes against humanity during the 1999 conflict in Kosovo. The other five high-ranking Serb officials on trial were not so lucky; everyone got prison sentences.

  • From the Special Court for Sierra Leone: Trial Chamber I returned a verdict last week in the case of three RUF commanders. Not only were all three found guilty on an impressive array of charges, but “forced marriage of captured women” made its debut as a crime distinct from your run-of-the-mill sexual violence charges. So congratulations to the prosecution for the first (and second and third) ever conviction for forced marriage under international criminal law!
  • From the Special Tribunal for Lebanon: Not much to report yet other than yes, we have a new tribunal on the scene in the Hague. (Good thing, too, because the ratio of Dutch people to international lawyers was getting perilously close to 1:1 around here.) Its purpose is to “try all those who are alleged responsible for the attack of 14 February 2005 in Beirut that killed the former Lebanese Prime Minister Rafiq Hariri and 22 others.”

So that’s the news for now. See you in a few hours…

War Crimes Indictments = Serious Bizness

Check it out: My friend and former law school classmate Cecily Rose has a post up at IntLawGrrls telling us what’s wrong with the Charles Taylor indictment. Cecily spent a year working at the Special Court for Sierra Leone, so she knows what she’s talking about.

She argues that a pattern has developed at the Special Court of pleading joint criminal enterprise (JCE) in ways that “threaten the right of the accused persons to have notice of the charges against them.” This may not seem like a big deal at first blush; but it is, and not just because of the fair trial rights issue.

The Special Court has a very narrow mandate, allowing it to prosecute only those “who bear the greatest responsibility for serious violations of international humanitarian law and Sierra Leonean law committed in the territory of Sierra Leone since 30 November 1996.” Consequently, there is a strong, and potentially problematic, incentive to find ways to prove that a small cadre of prominent individuals are responsible for all of the war crime-iness that occured during the conflict. (Am I the only one who feels like the Sierra Leone conflict involved a sufficient degree of one-upmanship that some people are going to be VERY disappointed to have someone else get credit for their painstakingly designed atrocities?)

As Cecily points out, this makes JCE an extremely important form of liability because the prosecution does not need to show that high-ranking officials like Charles Taylor “personally committed any of the alleged atrocities.”

However, even poodle-owning possible cannibals have rights, and in the context of JCE allegations, that means that the indictment has to allege material facts such as the nature and purpose of the enterprise which which the indictee is charged. (It would be pretty hard to defend your case without this information, right?) The Taylor indictment fails to do this.

Cecily tells us that during opening arguments in 2007, the Prosecution argued that:

“Taylor participated in a common plan to achieve and hold political power and physical control over the civilian population of Sierra Leone through criminal means involving a campaign of terror against the civilian population of Sierra Leone.”

However, in an Amended Case Summary filed two months later, this was altered to allegations that:

“Taylor participated in a common plan to carry out a campaign of terror . . . in order to pillage the resources of Sierra Leone.”

In its current incarnation, the Taylor indictment bears little resemblance to either of these allegations and doesn’t even mention the nature of the JCE. It charges that Taylor is responsible for crimes that:

“amounted to or were involved within a common plan, design or purpose in which the ACCUSED participated, or were a reasonably foreseeable consequence of such common plan, design or purpose.”

Obviously, this is not good. The defense has argued that these shifts in the JCE allegations have resulted in a failure to provide Taylor with adequate notice of the charges against him. The Trial Chamber has yet to rule on this issue.

As Cecily points out, though, the threat to Taylor’s ability to defend is not the only problem: “By oscillating from one common purpose to another, and by failing to anchor its arguments in text of the indictment, the Prosecution has not only provided Taylor with untimely, inconsistent, and confused information, but it also may have substantially weakened its case against Taylor.”

If you’d like to read more, here is Cecily’s soon-to-be-published article upon which her blog post is based.

Get That Ice Or Else No Dice

Tonight I watched “Diamonds of War: Africa’s Blood Diamonds.” It’s a 2003 National Geographic special that follows investigative reporter Dominic Cunningham-Reid as he reconstructs the path diamonds take from the mines of Sierra Leone through the exchange houses in Antwerp to the jewelry stores of Manhattan.

There’s perhaps a bit too much along the lines of: “I wondered how it would feel to bleed to death in the hot African sun,” but Cunningham-Reid uncovers some interesting stuff, such as the fact that digging up a pound of diamonds requires the movement of 1800 lbs of earth. After attending a meeting of the Kimberley Process (the organization of diamond producing states agreeing to certify all diamond exports as non-conflict diamonds), he discovers that, in fact, 60% of the diamonds produced in Sierra Leone are smuggled out of the country and never enter official, Kimberley-monitored channels at all.

Cunningham-Reid visits the SL diamond fields, noting the absence of armed guards or machinery of any kind. Mostly it’s just guys standing ankle deep in dirt, sifting through pebbles. He reacts with barely concealed horror when a man excitedly tells him that the diamond he has uncovered following 7 straight days of fruitless labor will fetch him the equivalent of $7 at the local market. I got a little bored at that point because like, blah blah blah, sometimes people are stuck doing work that’s dirty, degrading, or dangerous; do we really need to conflate it with slave labor compelled by vicious warlords with a penchant for maiming people who piss them off?

Anyway, I think the high point of the documentary was one of Cunningham-Reid’s interviewees at the Kimberley Process meeting earnestly declaring that nobody with “any sort of a conscience” could wear a diamond knowing it had financed “one of these conflicts.” To which I say: Take a look at theknot.com and let me know how that positive-opinion-about-humankind is holding up…