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In the fall of my sophomore year, I took “ICPR H302 Bodies of Injustice: Health, Illness and Healing in Contexts of Inequality,” a required course for CPGC fellows returning from a summer internship.  This intense, interactive, seminar provided a vehicle for understanding social justice through the lens of public health.  I had gotten a glimpse into epidemiology from taking intro biology classes, but had never looked at the social determinants of health in an academic setting, and learned a lot from studying specific case studies.  What was amazing to me is that some of the most entrenched non-infectious public health crises, such as sexual violence, “food desserts,” and a lack of access to healthcare, occur everywhere in the world, from the poorest countries in the Global South, to the richest developed nations, including the U.S.  What is also remarkable about these crises is that there is empirical research showing how they can be solved, or at least allayed.  Perhaps “world peace” will forever remain a cliché, but providing access to affordable produce in a poor neighborhood might be within reach.  The class was especially important to me because it allowed me to connect development and global health scholarship with the “on the ground” experience I’d had over the summer.  Below is a reflection I wrote after reading Jeffrey Sach’s The End of Poverty, as I tried to make links between his work and my own experiences.

             Jeffrey Sach’s ideas about scaling up in chapters twelve and thirteen resonated with me throughout the rest of the book, especially when he talked about his “Millenium Development Goal-based poverty reduction strategy” later in chapter fourteen. “Scaling up” HIV/AIDS service organizations was a big topic of conversation amongst the activists and NGO workers I got to know this summer, and was also a big focus of the UNAIDS conference I attended.  As Sachs explains, “The main challenge now is not to show what works in a single village or district – though these can be of great importance when novel approaches are demonstrated – but rather to scale up what works to encompass a whole country and even the world.” (259)  It is immediately clear when talking to anybody involved in this kind of work that scaling up is not nearly as easy as it sounds, even when there is ample money available to help a program grow.

            One community-based organization I spent a lot of time at this summer is “Kelompok Sayang Keluarga,” an organization that provides services to the families of people living with HIV, such as a weekly support group, education services, and counseling.  It is located in Singaraja, on the north coast of Bali.  KSK was started by a father after he found out his 20 year old daughter was diagnosed as being HIV positive, and has been remarkably successful in reducing HIV/AIDS stigma in Singaraja.  The organization was originally intended to only serve the one district, but in May received an enormous UNAIDS grant to start programs throughout all of Bali.  The money was met with trepidation and concern – the task of moving from a one-room office with only a handful of staff members to a far-reaching organization was daunting.

            My research partner decided to ask Ruth Messinger [who came to visit Haverford in Fall 2009] about scaling up during her visit to the other CPGC class, with KSK in mind.  Messinger replied that the American Jewish World Service now only gives enough money to sustain organizations or programs – never to make them bigger.  She explained that scaling up existing projects is one of the most difficult things she’s ever done in her capacity as president of AJWS, because small, grassroots NGOs often don’t have the expertise necessary to affect a wider area and because they are often overwhelmed and paralyzed by such a large influx of money.  Additionally, she felt, like many of the people I met in Indonesia, that what works for one village might not work for the one next to it.

            I appreciate the examples scaling up in The End of Poverty of (259), but most of the projects Sachs writes about started on a huge scale, and only had to get even larger – the Rockefeller Foundation’s Green Revolution began with crops throughout all of Mexico; the WHO’s Smallpox Eradication Unit immediately started helping poor countries around the world; and the Onchocerciasis Control Program was initially set up in eleven West African countries.  As impressive as these programs might be, they do not stand as examples of how to scale up “what works in a single village or district.”  Sachs’ “MDG-based poverty reduction strategy” will require huge amounts of scaling up existing programs, but he only briefly addresses how to do this for small programs that are very effective on a local level.

            Nonetheless, the components Sachs gives for a “public management plan” would be very useful for Keluarga Sayang Kelompok to keep in mind as it grows – especially if there is a hope to eventually reach other parts of Indonesia or Southeast Asia.  Decentralization is key.  “The details will have to be decided at the ground level, in the villages and cities themselves…decentralized management of public investment is therefore a sing qua non of scaling up.” (278) It is hard for community members currently working at KSK to know what will work (and what is needed) in urban Denpasar, a rural village in the mountains, or tourist-laden Kuta.  Concerns and sources of stigma will undoubtedly be different for families living in different parts of Bali.  Another vital component is the importance of training.  Sachs explains that the public sector “lacks the talent to oversee the scaling-up process,” (278) and that capacity building training programs are therefore necessary.  The other components of Sachs’ plan – information technologies, measurable bookmarks, audits, and monitoring – all make sense for HIV/AIDS organizations in Bali that are trying to grow, including KSK.

            I wish that he had given examples of small, local programs that have successfully grown in size and outreach.  Sachs emphasizes that financing is not sufficient for scaling up, and that implementation requires time – maybe we just haven’t waited long enough for the process to take place.  Some of the people my research partners and I spoke with, however, felt strongly that community-based organizations should not try to get bigger, that instead there should be an emphasis on starting entirely new, autonomous organizations to do similar work.  From an economic perspective this obviously doesn’t make a lot of sense, but for many, it does on a practical and efficacy level.  “Scaling up” is a phrase thrown around so often within the HIV/AIDS community that it has almost become clichéd.  At the conference I attended, the WHO handed out DVDs that were supposed to serve as toolkits on “Scaling up HIV testing and counseling services.”  Many sessions had similar titles that outlined strategies comparable to Sachs’.  From my entirely anecdotal perspective, it seems like there are good plans about how to scale up, but fewer organizations who have actually tried to implement them, and even fewer who have been succesful.