Jim photographed these girls near the site where the larger RCT is taking place.
Today, we are announcing the results of a five-month study of alternative sanitary technologies. The findings of the study and links to details of the technology can be found here. In sum, we found that while well-designed cloth pads offer an advantage over customary methods where disposables are not available, poor rural girls will choose disposables most of the time, even when given free cloth pads. Keeping materials clean in remote areas remains a challenge that agencies need to take seriously. A papyrus pad tested very well, assessed as being “as good” or “better” than commercially-available pads. But girls resisted using an incinerator because of local taboos.
The ground research was done by Paul Montgomery, Laurel Steinfield, and me, as part of the larger team doing a randomized controlled trial elsewhere in Uganda (led by Catherine Dolan).
I learned lessons about leadership on this study, some of them humbling. I understood the realities of material choice and production in Uganda in a way I had not understood before. And there were many of those moments of fieldwork we have come to refer to as “rubber research” (because it bounces around in a way very unlike the textbook descriptions from which we all learned how things are supposed to go). I want to share that stuff here, since the findings of the study are available elsewhere on the site.
Paul Montgomery and I went to Uganda on the scouting trip with Julian Tetlow (and, of course, Jim). Julian is an educator with long experience and high credibility in the developing world, especially in Uganda. He had heard me talking about sanitary pads on BBC radio when he was visiting in Abingdon, which is just down the way from Oxford. He emailed me to see if he could come up and talk. I said “Why not?” In a claustrophobic little conference room at the Said School, he told me he wanted to give back to an area in the mountains of Uganda where he had spent his early career. He intrigued me with his description of the various subcultures that lived at different heights, and of the dedicated teachers and schools there. Between us, we also knew of several people developing interesting technologies around the sanitary care issue in Uganda. And we were both interested in women’s economic empowerment. So we decided, on the spot, to work together. It was one of those spontaneous decisions that changes your life.
I like it when the school picks bright colors for the uniforms, but a dark color is best for girls who are worried about sanitary issues.
So we end up in Uganda, courtesy of a grant from Green Templeton College. I was wanting to visit the Nyaka Orphan School to see how they had gotten along with a pattern we had sent them for making their own cloth pads. Then we also wanted to get to know Moses Musaazi, a professor we had met only through email, who had invented a papyrus-based pad and an individual level incinerator. Julian had made contact with the KMET people and I had a UK student who had organized a thing called “Project Mwezi” to make an innovatively-designed pad. These two organizations were in Kisumu, which meant we were going to drive across the border into Kenya, something I will avoid doing again (ground immigration across African borders being a dodgy business). Then, there were Paul Grinvalds and Sophia Klumpff, a couple (yes, a cute couple) working closely with girls to develop their pads, following a process that I could recognize as real consumer research (which nobody does in development work, but they should because they would make fewer mistakes if they did).
We had a great trip. We learned, courtesy of the Nyaka School experience, that the materials you use to make pads are very important: they had chosen terry cloth, which dries hard and rough in the sun and so is no good for use in such a delicate place on the body. We saw Moses’ MakaPads operation from cutting the papyrus to grinding and drying it, then the whole hand-crafted process of mulching office paper and rainwater to add to the papyrus, spreading it out on ordinary window screens to dry, and finally cutting and assembling the pads. Julian introduced us to some fabulous people in the place of his early career, including a charismatic headmaster and two dedicated headmistresses, who agreed to let us conduct a study among their students. We worked it out that, if we were very careful, we would have enough money left from the initial grant to do a trial with all the products we had identified.
Agnes was with us throughout the study and has continued in the larger trial. Here she is interviewing a girl, which must be done privately and gently, because of the sensitive topic.
Two months later, I went to set up everything at the schools and train a team of research assistants recruited by Plan Uganda, our partner in the larger trial we were also setting up (that trial is still ongoing). We got the pads shipped in, but the ones coming from KMET in Kisumu were put on the wrong bus and when they finally arrived there weren’t enough of them. I was lucky that I now had a local friend in the owner of the driving company, Sam Mugisha, who could help me figure out how to retrieve them–including driving several hours himself! Especially in Africa, things often don’t go as planned. You need to be flexible and you need to be cognizant of your own need for help. No sense in going in all high-handed and full of yourself, because you can count on it that you will eventually need to beg for assistance.
Here we are sorting the pads into treatment groups. It took forever and I was frantic because the KMET shipment got lost somewhere between Kampala and the Kenya border.
With cheerful help from a great group of ladies in the town where the secondary school is located, we sorted and bagged the pads according to treatment group. We got all the rosters ready. Then I went back to Oxford, expecting Julian Tetlow to return to execute the study three weeks later. But Julian’s retina suddenly got detached and he couldn’t go.
So, the local team, led by Edison Nsubuga of Plan Uganda and Rita Nabuzale, a recent graduate of Makerere University (who I had met purely by chance in the cantina where I was staying), pulled together and went back to the field, bringing with them a team of six research assistants. The teachers and the headmaster, along with the same group of ladies who helped prepare the materials, worked with this research team to execute the first round of work. That included the distribution of all the materials to the right girls, instruction in how to use and wash the pads, demonstration of the incinerator, and the collection of demographic data from the entire sample at the secondary school (n=402). They did it all without a single error. And without me!
Latrines at one of the test sites.
Well, not entirely without me (though it was a lesson in my own dispensability). I spent the whole time trudging around Oxford, trying to get them money. I had arranged in advance for everyone to be paid, including all the accommodations and meals for the whole team. But this all went haywire because Oxford’s finance department decided, in their infinite wisdom, that these must be employees who needed to go through immigration vetting and be put on salary–and cancelled all their payments without telling me anything. I found out when the money didn’t show up. Which just goes to prove that things go wrong in other places besides Africa. So I spent the whole week pulling installments out of my own checking account, then walking over to the Western Union and wiring cash to the team in Uganda. I felt like a drug dealer. On the other end, Edison or Rose Manana, who owns the B&B where we all stayed throughout the study (Rose’s Last Chance Cantina–try it if you’re in the neighborhood), would have to take the bus into the nearest town to get the cash. And, of course, it was a matter of utter trust that they would use the cash as intended and provide receipts for which I could get reimbursed. Which, of course, they did. And that’s because most people in Africa are scrupulously honest, despite the stereotype of corruption we get from the world press.
All through the week, I communicated with them via Skype, on the iPads that had been provided for the study. It was hilarious. Rita and Edison would appear on the screen at the end of the day, giggling from the four-wheeler that had been parked where the signal was good.
Carolyne Asumpta has been a leader among our research assistants throughout our work in Uganda. She played an especially important role in our research into household purchasing decisions.
That’s because it was in this study that we developed a way of collecting data in remote areas that we have now carried into other work in the developing world. Working in partnership with the ATLAS laboratory at the University of Illinois, we have become accustomed to developing SurveyGizmo questionnaires for use on an iPad, working iteratively with ground partners to get the language right. This is not in itself a big deal. But we have developed a procedure whereby we go into the field in the morning, then upload the answers at the end of the day–with the iPads, we can nearly always do this even where there is no internet (important because where we work, there is almost never internet). Back in Illinois, the ATLAS team gets up about the time we are leaving the field. They review the data while we shower, eat dinner, and so forth. Then they feed back to us any questions about or problems with the data we have uploaded. We sit around a table (or a jeep) with the day still fresh in our minds (even if our bodies are exhausted) and can usually answer most of the questions then and there. If not, since we are still on site, we can go back the next day or make a few phone calls, and clear up any problems. This means we return from the ground work with completely clean data. It saves so many headaches.
In this particular test, though, we did have some funny moments. I went back for the final data collection five months later, when the area was plagued with big rainstorms. Signal even for cell phones was very weak and spotty. So I would stand out in an open grassy space next to our B&B, texting with Maryalice Wu and her team, trying to resolve the issues. What a mess! There was a big mudslide that week and everything. Roads washed out. I’ll never forget it. But now, we just plan on doing the data collection in real-time tandem with our friends in Illinois. Catherine doesn’t even like to go to the field anymore without ATLAS on the line!
Great natural beauty alongside great poverty is the order of the day in this part of the world. Nevertheless, the sweetness of the people made me think I could retire there.
About three weeks after the first round of data collection, we got an email from a Peace Corps worker, John Emami, who was living at the secondary school where the main test was going on. He wanted us to know that the girls had told him they were not using the incinerator because they were afraid that burning their menstrual blood would render them infertile. Oh, my goodness! I swear I had asked about stuff like that on the first trip, before we ever installed those incinerators. But it is exactly the kind of thing people don’t like to tell you. So, this time, Paul hopped on a plane. He and Rita went out to the site and sat to talk with the girls, as well as all our local friends who were helping us with the study. Rita, who actually comes from the area, was visibly pregnant at this point (but also very urban and rather glamorous), so we felt surely she would have some credibility. They reassured the girls and put all kinds of extra measures in place, but in the end, we felt we just didn’t know whether they used it or not. Of course, they said they did. But, really, we couldn’t be sure.
Laurel and Rita got along famously. I would say they were like two peas in a pod, but it's pretty obvious there are three peas here.
Now, mind you, people have weird superstitions about menstrual blood all over the world. It is the most taboo topic there is, therefore full of all kinds of silliness everywhere you go. So this wasn’t just some peculiar Ugandan thing. But it really shot down the test. Nothing to be said about it. I hope people will keep working with that technology, as I personally think it is necessary and brilliant.
We were really tight on time for the final data collection because Laurel and I were piggy-backing on the RCT to save money. I was stressed about staying on schedule with the interviews. At the end of the second day, the team of research assistants came to me and asked me to come to a meeting with them in the large, airy cabin they stayed in at Rose’s. I was apprehensive. I couldn’t imagine what they wanted. They advised me that they needed more control over their own work, that they couldn’t continue on the schedule I had set for them. They told me that if I would let them manage themselves, they would promise to make the deadline. It seemed reasonable, but this is not the way “rigorous research” is conducted (you are supposed to maintain control, right?). Nevertheless, these were fine young women and they were asking me to show them respect. And to evidence a little humility myself. So I took the risk and said ok. I could tell in the first moment, from the relief and gratitude in their faces, that I had made the right decision. And, of course, they made the deadline, with time for a shopping trip on the way back to Kampala!
From left, Clare, me, and Rose. In front of Rose's rose bushes, of course.
I made two friends in the town that I hope I will keep for life. One was Clare Wambazu, who was the headmistress in one of the primary schools where we tested the pads. The other was Rose Manana, who is one of the most entrepreneurial women I have ever met. These two picked up the slack for every problem that arose and brought an aura of local approval and gracious dignity to the entire project. All through the study, they would text me from time to time. There I would be at some grand dinner in Washington or some conference in New York or a meeting in Oxford, and suddenly would bubble up from Rose or Clare, “Mlembe, Linda! How are you?” It reminded me of what was real, though I admit there was a certain hilarity in the incongruousness of such moments.
I said “good-bye” to Julian from the rose garden at the Last Chance Cantina. I don’t know if I will ever see him again, but I am grateful for what his partnership made possible. It was an extraordinary experience. One of the best in my life. I mean, it’s just a little study, another data bit on the pile of knowledge about girls’ education. But, for all of us who were there, it was more than research. It was proof that people can pull together across time, distance, and culture to solve our problems.