Archive: July, 2013

The Promise of Rural Health Innovation in Djibouti









This is the unlikely — and unfinished– story of a public-private partnership for development, linking the Gulf emirate of Dubai, the Red Sea State of Djibouti and the United States Agency for International Development (USAID).

In 1998 Ethiopia and Eritrea fought a brief but brutal war.  Ethiopia lost use of its former two main ports (Assab and Massawa) to Eritrea, and almost all of Ethiopia’s exports and imports (Ethiopia’s 2011 GDP was close to 40 billion dollars) shifted onto a thin road linking Ethiopia’s capital of Addis to the port of Djibouti. Dubai was at this time seeking a beachhead in Africa through which to export its combination of port management services, free trade zones, customs management and amenities.  Developments in Ethiopia, a precipitous drop in trade through neighboring Aden, Yemen due to the USS Cole Bombing in 2000, and Djibouti’s strategic location at the foot of the Red Sea, made Djibouti an inspired — and profitable–  bet.

A 2008 presentation in Djibouti by the late Gail Goodridge, then with Family Health International (FHI), converted me to the rather brilliant idea of using transport corridors as a vector for delivering social services to a number of disadvantaged populations.  Dr. Jeff Ashley, a veteran USAID hand, conceived several years before of the idea of using “augmented truck stops” along major transport corridors in Africa to get out the message about HIV/AIDS.

With Dubai catalyzing nearly $1.3 billion in investment in this state at the foot of the Red Sea — paying for the construction of the most technologically advanced port in East Africa, a luxury hotel, and roads, among other things–  both Dubai-led external investors and Djiboutian government were under pressure to show that this relationship was generating benefits for Djibouti’s urban and rural poor (Djibouti’s unemployment rate is over 50%, and the country’s population of 800,000 is under continued threat of famine and drought).

As the Corporate Social Responsibility point person for Dubai Ports (DP World) from 2008-2011, I oversaw a three-year campaign to broaden the ROADS remit to include the provision of primary healthcare services and small-scale commercial activities, enabled by advances in solar and satellite wireless technology.  We revamped the “truck stop” concept and persuaded Dubai Ports and its suppliers to invest in more permanent healthcare structures according to a “hub and spoke” model, which has since been successfully implemented in other countries in the Subcontinent.  After Djibouti, the next recipients were to be the Maputo Corridor in Mozambique, the port of Dakar, in Senegal (both of which were run by DP World).

The model, and the division of labor, looked robust:  Dubai Ports would pay for the hard infrastructure that USAID funding did not allow, and the contractors (in this case, FHI) would work with the Djiboutian government and local hospital to make sure local resources were trained to staff the facilities.

During stage I, the base camp at a truck stop called “PK12” (for its distance twelve kilometers from the city center), essentially two shipping containers welded one on top of the other and furnished, was outfitted with solar panels (electricity was prohibitively expensive, so the facility was dark 9 hours a day) and a VSAT internet connection, so visiting truckers could Skype their relatives, and pull up a variety of health-related information, some in the form of software donated by DP World suppliers. Planned small-scale commercial activities included mobile phone charging stations and a small canteen.

Meanwhile, we set about designing a prefab clinic (manufactured by Italy’s Edil Euganea)  which included exam rooms, a lab, a canteen, an audio-visual room, easily sanitizable surfaces and separate entrances for male and female visitors (in deference to the country’s conservative mores). Importantly, we thought hard about what would make the clinic more attractive to its users.  We designed the facility, within budget, to accommodate 30,000 individual visits a year.  With the ‘hub clinic’ was built, the existing, upgraded ‘SafeTStop’ was to be moved up the highway to Dikhil, closer to the northern border.  Connectivity between the two posts, and other posts over the border in Ethiopia, would serve as the skeleton of a widening network of services, where a mobile patient’s records would be available throughout the network.

Thus, a USAID “Global Development Alliance” (GDA) linking Dubai Ports, the Djiboutian government, and the United States was launched in 2009, formally, in a ceremony attended by the Djiboutian Minister of Health, Senior DP World executives, and representatives from USAID and FHI, and touted as the “First Ever U.S.-Djibouti Public-Private Partnership” (the USAID link has since been taken down).  A Dubai and Kenya based company, Intersat/ SPARC, installed the solar panels.

Here’s where things started to go awry:  Dubai’s increasing preoccupation with the fallout of the 2008 financial crisis, a tussle with Djibouti over an exiled ex-Djibouitan official, and an odd drop-off of interest by contractors employed by USAID, left the upgraded unit operating much as it had previously been, and the new clinic sitting unassembled for the better part of two years.

No longer working for Dubai Ports, I and a group of colleagues worked with Edil Euganea and other entities over the course of 18 months to assure the new prefab unit was not sold for scrap for delinquent payment (it came close), and lobbied with USAID and senior government officials to make sure programming and training was not suspended or abandoned.

Now, in mid 2013, a somewhat promising thaw in Dubai-Djibouti relations has brought the clinic concept back to life:  Dubai unsealed the containers and the 2000 sq ft unit — the one pictured above– was assembled in less than two weeks by, using a combination of Djiboutian, Italian and Dubai labor.

Certainly better late than never, but what of the original plan?  Will the new clinic be staffed by purpose-trained Djiboutians in a collaboration between American and Djiboutian medical personnel?  Will the original PK12 structure be moved up the corridor to the town of Dikhil to establish the second node?  Who will make sure the clinic and the outpost are working properly?

The success of this venture is all the more critical, as every one of the stakeholders– Dubai, Djibouti, the U.S. government, the Ethiopian transport workers– has a stake in the outcome.


The California-Libya Connection

Despite being almost 7,000 miles apart, California and Libya have an interesting history, a similar climate, and a relationship that’s worth watching.

At independence in 1951, Libya was one of the poorest countries in the world, exporting scrap metal and dates. After the discovery of oil in commercial quantities in 1958, Libya began sending promising graduates to the United States to acquire skills needed to manage the country’s natural resources. Future petroleum engineers went to ‘oil schools’ like Oklahoma, Kansas and Texas A&M, while those focused on agriculture and water (a critical issue in a country that is over 90% desert), attended Federal land-grant universities such as U.C. Davis and Berkeley. Libya’s most prominent hydrologist studied at Davis in the 1970s (perhaps it is no coincidence that California artichokes grow beautifully in Libyan soil).

As Gaddafi’s policies became more erratic and violent, nearly two decades of bilateral and U.N. sanctions reduced Libya’s contact with the West. During the rapprochement with Libya in the late 90s and early 2000s educational links began to re-form, if tentatively. The 2011 ‘Libyan Spring’ spawned literally hundreds of local civic organizations, and prompted a large number of the Libyan diaspora– many from Texas and California– to return to help create a new, more open state.

This year, one might say the Libyans have returned to California. Two out of a record six Libyan candidates were chosen to participate in the prestigious U.C. Berkeley-Beahrs Environmental Leadership Program (ELP). The ELP, in its 15th year, is designed specifically to boost the effectiveness of promising mid-career professionals from developing countries, through modules on resource management, global warming, food security, etc. and workshops on negotiation and organizational management. Two past ELP participants have won the Goldman Prize (Environmental Sciences’ analog to the Nobel).

Khaled Ben Halim, one of the 2013 ELP Libya contingent, relocated to Tripoli from Texas during the revolution with the single-minded goal of protecting animals from abuse; “conservation and animal welfare is usually last on the list of concerns during war,” Ben Halim rues, “but these constituencies also need advocates, and I felt that was the contribution I was best able to make.” Ben Halim has been instrumental, among other things, in a campaign to rehabilitate the Tripoli Zoo, whose collection of hippos, oryx and other African fauna barely survived the revolution, due to the efforts of volunteers. On the sidelines of ELP, Ben Halim hopes to create a relationship with the U.C. Davis School of Veterinary Medicine.  Rida Sherif, a final-year forestry Ph.D. candidate at the University of Mississippi, is concerned with the impact of improved forest management on desertification. ELP participants from the state of Mali, itself severely impacted by the revolution in its neighbor to the North, improve access to education through feeding programs.

Professor David Zilberman, ELP program co-director, says that “sustaining natural resources in post conflict nations is a major priority for the College of Natural Resources, and we are very eager to support Libya’s future environmental leaders.”

My experiences at Berkeley (Ph.D., Agricultural and Resource Economics), and as one of the first U.S. diplomats in Tripoli from 2004-2006, shaped much of what I’ve done since, including co-founding the Avicenna Group, which has specialized in building relationships between U.S. and Libyan institutions, particularly in the area of acute care and emergency medicine.

Ambassador Christopher Stevens, whose ties to California and U.C. Berkeley were widely reported, served sequential assignments in Libya as Deputy Chief of Mission, U.S. Envoy to Benghazi, and then, Chief of Mission in Libya.  Stevens was critical in generating U.S. support for Libya during and after the 2011 revolution, until his tragic death last year in the attack on the U.S. Mission in Benghazi at the hands of extremists– an act that had more consequences on Libya’s trajectory than many would care to admit.

Anne O’Leary, who retired recently from the Foreign Service, was the first permanently assigned Public Affairs Officer (PAO) in Tripoli, and in that capacity, created a framework for future US-Libya student exchanges. O’Leary grew up in the Bay Area, and was ‘Diplomat in Residence’ at U.C. Berkeley from 2007-2008. One of her successors, Mietek Boduszynski–you guessed it, another Berkeley Ph.D.– has been responsible for keeping U.S.-Libya educational relationships running, through the current turmoil.

After the September, 2012 attack on the U.S. Mission, the Avicenna Group shifted its focus to the problem of how to provide technical assistance when a sustained in-country presence is either not possible, or very difficult. The organization, with support from American and Libyan donors, has been working closely with ELP, and the Blum Center for Developing Economies to engage advanced graduate students in Engineering and Public Health, for example, to address a series of practical questions such as “how to design an ambulance dispatch system in a city without physical addresses”, “how to train novice medics in the field via Internet-based courses.”

In parallel, Avicenna has been working with faculty at the University of San Francisco (UCSF)-Global Health Sciences, and the U.C. Berkeley School of Optometry, to scope projects in, for example, retinal scanning for diabetes (assisted by a Libyan Ph.D. candidate), hospital administration, planning for acute and emergency care, and sustainable design. California-based firms with international interests, like the Berkeley Research Group, a law and economics consultancy, have helped underwrite the costs of ELP’s Libya outreach.

Recent exchanges have also been cultural: several in Libya and California helped bring noted Libyan artist Mohammed Binlamin to Davis in early April, to participate in a Stevens memorial exhibition, hosted by the John Natsoulas Gallery. Binlamin spent several days in Berkeley, visiting with local artists and touring a local foundry and galleries, with the goal of bringing California-based artists to Libya.

Collectively, the Libya-California links are multi-faceted, decreasingly random, and neither permanent nor fail-proof– but with attention, they have the potential to contribute to a more stable Libya, a more creative U.S.-Libya bilateral relationship and new approaches to the provision of meaningful, cost-effective assistance to post-conflict states.