Part 1: Ethical Decision-Making
In a certain region of East Africa, the growth of ~35% of the children is stunted due to poor nutrition. Traditionally, maize and bananas are the items most commonly made into a gruel and fed to infants beginning at ~2 months of age. The gruel is integrated into a child’s diet to complement breastfeeding until they are ~24 months of age. Mothers in the area firmly believe that the gruel is highly beneficial for their children, but scientific research has shown that it does not provide some key nutrients. HIV/AIDS is very prevalent in this region. The World Health Organization recommends exclusive breastfeeding until an infant is six months of age, but the longer a child nurses when the mother is HIV+, the greater the chance that the virus will be transmitted to the child. You have received a grant to establish a women’s cooperative in this region. The donor’s intent is to simultaneously improve the nutritional status of children and improve the livelihoods of rural households. The grant for the women’s cooperative has sufficient funds for the women’s group to process and market a nutritious, shelf-stable porridge made from a large mix of locally grown produce. The nutritious porridge is intended to wean children off of breast milk at about 6 months of age.  Approximately 500 women from three contiguous sub-locations have indicated their interest in joining the cooperative, in hopes of improving their livelihoods. However, they are skeptical of the porridge and its use as an early weaning food. Cash crops as well as subsistence crops are grown in the area, including maize, sorghum, cassava, several varieties of legumes (dried beans), French beans, coffee, pineapple, bananas, pumpkins, tomatoes, carrots, kale, white (Irish) potatoes, and sweet potatoes. Pesticides are typically used in growing some of these crops and can result in adverse health implications for infants. How would you address the ethical health issues associated with prolonged breastfeeding in an area where there is a high prevalence of HIV/AIDS and few women are tested for the virus, very early introduction of supplemental foods to the diets of infants, and the possibility of pesticide residues in foods developed for infants and young children.  What are your next specific steps to develop this cooperative? 

Because this is a very complex case, it is integral to first define the facts of the situation and the actual ethical dilemma at hand:

FACTS OF THE CASE

• High HIV rate
• 35% of the children stunted
• Mothers who are HIV positive risk transmitting to child if they breastfeed
  • Few women are actually tested for the virus
• Pesticides typically used in growing the crops
• Current food they are getting isn’t nutritious
• There is a grant to establish a women’s cooperative
• The goal is to wean children off breast milk at roughly 6 months old

The main goal is to improve the nutritional status of the children AND improve womens’ livelihood.

Ethical Issue: How can the women’s cooperative prevent transmission of HIV from mother to child AND prevent children from eating pesticides? Is it worse to get HIV or eat pesticides?

Next, to address this issue we obviously want an outcome that positively effects all the parties involved in this situation. Therefore, we must identify the stakeholders and their motivations:

STAKEHOLDERS AND MOTIVATIONS

• Mothers
  • Want children to be healthy
  • Don’t want to pass HIV to children
  • Don’t want children to have adverse effects from pesticides
  • Want children to be properly nourished
• Children
  • They are directly impacted by the breastfeeding/pesticides
  • They need to obtain all required nutrients
• The donor
  • Wants its money to be spent properly
  • Wants a good reputation
• Us
  • Provide nutritious porridge for the children
  • Ensure the cooperation is built right and is sustainable/scalable
  • Invested in seeing the impact through
• Women’s Cooperative
  • Wants to provide children with a nutritious porridge to wean children off of breast milk
  • Are skeptical of the impacts of pesticides and of HIV transmission
  • Wants to attract investors to the cooperative
  • Want to bring in a stable income to support their families
  • Wants good reputation
• Local cash crop farmers
  • They grow the crops that are being bought for the porridge
  • Financially invested

From this information, possible solutions can be formulated and of course the pros and cons and implications of each solution must be considered:

POTENTIAL SOLUTIONS

Solution 1: Have the cooperative grow their own produce (pesticide-free) and employ more local women

Ethical Principle: Duty-Based

• “Do only that which you would want everyone to do”
• We would not want our children and communities eating crops sprayed with chemicals

Pros:

• Creates jobs for women
• Not only the cooperative but the community as well can have access to clean and healthy crops
• Can be fully in control of the crops
• Children will get the nutrition that they need

Cons:

• It may cost more setting up another piece of land
• Have to educate the women on farming practices
• Will put some farmers out of business

Solution 2: Wash the produce when it gets to the cooperative
Ethical Principle: Virtue-based thinking

• “What is ‘honest’ depends on social traditions, history, etc. the gruel the children receive already has pesticides and the solution would reduce HIV transmission while possibly  decreasing pesticides in gruel.
• Ethics often times can rely on judgement

Pros:

• There would be no more/significantly less pesticides in the food
• They get the nutrients they need
• Don’t need to breastfeed so avoid HIV transmission
• Cheap way to avoid pesticides

Cons:

• The water may not be clean
• Hard to measure if washing it is effective
• We’d need a water filtration system
• If the pesticides were treated with wax then they could be trapped beneath the waxy surface

 

Solution 3: Develop a vitamin supplement to add to the gruel so that children can continue eating gruel but also be nourished
Ethical Principle: Consequence-based thinking

• Although the children would still be eating pesticide-contaminated gruel, they would definitely be getting the nutrients they need through the supplement
• The benefits outweigh the negatives

Pros:

• They get the key nutrients that they need
• Don’t need to breastfeed
• Better than HIV
• Using the base recipe – may be cheaper

Cons:

• Probably have to import the supplement which might be expensive
• Still getting pesticides
• Could possibly alter the taste
• Supplements may not be as nutritious as incorporating healthy foods
• The mission is to create opportunities for women and this does not follow that

Before selecting the “best” solution, we can draw upon additional information that we have learned from experience that may be helpful. When first reading the description of this case, it sounded incredibly similar to the venture that our malnutrition team is trying to launch. The overall main goal (to improve the health and nutrition of infants) is the same as ours. We obviously did extensive research on this issue of actually getting safe, nutritious foods to infants. We have learned the importance of incorporating whole, nutritious foods into childrens’ diet, but have also learned about supplements that can be effective too if they need to be used. Therefore, because of this prior knowledge we were able to incorporate this supplement knowledge into one solution.

After weighing all the options, the best course of action would be solution 2: washing the produce with filtered water. This will easily get rid of the pesticides in the food and children will be able to eat clean and nutritious food. Although it might be expensive to get a water filter, this will be a one-time upfront cost. There might be slight maintenance costs in the future that the cooperative will have to cover (because the donor money will eventually run out) but this will be much cheaper than starting up a new farm, so it is better than Solution 1. Additionally, it is better than Solution 3 because eating whole foods is much better than using supplements and Solution 3 still gives children pesticides. This solution will obviously benefit the children and their mothers because they will be able to consume healthier foods. This solution will benefit the women’s cooperative because they are achieving their goal of providing a healthy and safe porridge for the children. The donor would be benefitted because he is supporting clean food services and making a great reputation for himself. Local cash crop farmers would still be making a profit and benefitting from the venture so they would remain happy. Lastly, me, as the person overseeing this choice, would achieve the goals of providing nutritious porridge for the children and ensuring the cooperation is built right and is sustainable/scalable.

In terms of the implications of this solution, the changes to the venture in general will be minimal, which is a positive thing. To begin, there may be an economic deficit because the water filter could be a significant cost. However, in the long term the investment in the filter will definitely pay off because the product will now be significantly cleaner and healthier. Technology-wise, there will be the implementation of another piece of technology as well as another step in the production process. This, at first, may be a little hard to deal with and teach the women, but it is an incredibly easy thing to learn how to use and do. In terms of the environment, we would be using water resources, but the outcome would be a decrease in the consumption of unhealthy chemicals, an incredibly positive environmental impact.

Some other implications that must be considered include:

• There would be an added step in the preparation of the porridge
• We have to educate the women to make sure they properly wash all the fruits and vegetables
• We have to know how to install a filtration system properly so that the water is clean
• They will have to upkeep the costs of maintaining the filtration system, even when the money from the donor runs out
• Children will not be getting as many pesticides and will be properly nourished

 Part 2: Grassroots Diplomacy
Six months after launch, the efforts of the women working in the cooperative you established are paying off, and business is thriving. The women work for about nine hours every day and earn KES 300 (about $3). Besides the wages earned, they have the opportunity to sell the produce grown on their small farms to the cooperative. This transaction is done at the prevailing market rate and helps the women make a little money on the side. The women like this arrangement because it saves them a trip (time + money) to the village market to sell their produce. The women enjoy working with each other and are happy with the cooperative; they have a strong sense of community and identity. However, there is one big problem. When a woman brings her hard-earned money home, she has no choice but to turn it over to her husband, father, or brothers. Rather than using the money to support their families, the men waste it on alcohol and frivolous things. Though the cooperative is thriving, it is not achieving the twin social outcomes of improving the nutritional status of children and the livelihoods of rural households.  As the entrepreneur who helped establish the cooperative, you are pained about the situation. Though you are loved and respected by the entire community, you do not have a direct say in the cooperative’s functioning. You are one of the seven members of the leadership committee that oversees all operations. The committee is elected on an annual basis and you have six months left on the committee, after which you will practically leave the cooperative completely. The other six members of this committee are local women who understand the problems and want things to change. They are not necessarily opposed to the men taking away their money but are upset that their hard-earned money is not used to feed their children. They are convinced that nothing can be done about it because that’s just the way it works in their community. 
What is your strategy to get the cooperative back on track to meet the twin social outcomes for the cooperative on a sustainable basis?

Again, to effectively address this situation we must state and evaluate the facts of the situation:

FACTS OF THE CASE

• The business is doing well
• There are multiple income earning opportunities (can sell produce from their own small farms)
• Women have to give money to husband
• Cooperative not achieving both improving nutritional status AND improving livelihoods
• I do not have a direct say in how the cooperative functions
• I have 6 months left to make a change because then I have to leave the cooperative
• There is a 7 person board
• Men waste money
• Women are upset that the money that they are earning is not being used to feed children, but don’t care that they are not in control of the money because it is culturally normal
• The children of the women in the cooperative are not getting the nutrition that they need

Ethical issue: How can we achieve the twin social outcomes without disturbing the culture?

Next, we must take into account the stakeholders and their relevant professional as well as personal motivations:

STAKEHOLDERS AND MOTIVATIONS

• Us
  • Personal and Professional
    • We want to achieve twin social outcomes
    • We want to financially empower women
    • We want the children of the women in the cooperative to be fed nutritious foods
    • We want cooperative to be successful
• Women in the cooperative:
  • Personal
    • Want to use the money they earn to support their families
    • Want their children to be healthy and fed
    • Want to have a good relationship with their husbands
  • Professional
    • Want to make money from the cooperative and their farms
    • Want the cooperative to be successful
• Children
  • Personal
    • Need the money that their mothers are earning to be used to support them
• Men
  • Personal
    • Want to be in charge of the money
    • Want to buy alcohol and frivolous things

Based off of this, 3 possible solutions can be formulated:

POTENTIAL SOLUTIONS

Solution 1: Compensate the women in goods (i.e. food, personal care products) instead of money

• Pros:
  • Women are able to support their families with goods and foods
  • The products and nutrients are going directly to the children in town rather than just to the cities
  • The children will have more resources
• Cons:
  • The husbands could be upset that the women aren’t bringing money back with them
  • Hard to always predict exactly what women need
  • The women may be less willing to work such long hours without monetary compensation
  • Might be hard logistically
• Saves face for
  • the women because they do not have to directly face their husbands, but are getting the desired outcome of putting the money towards the family
  • the cooperative because they would achieve their joint goals and run a more ethical venture
• Implications on relationships
  • Short term
    • Men may be angry at the women for not bringing home money
    • Immediate unhappiness within family units
  • Long term
    • Family will be better off so it may eventually build relationships in the family
• Implications on venture
  • Short term
    • The children will receive the necessary nutrition
  • Long term
    • The venture will achieve both of its goals
    • The children will have more resources and become more nourished

 

Solution 2: In addition to still paying the women regular wages, compensate for some of their wages in goods (i.e. food, personal care products)

• Pros:
  • Easier to integrate with the families because they are getting both money and resources
  • The products and nutrients are going directly to the children in town rather than just to the cities
• Cons:
  • Men can still waste money
  • Women may want to choose exactly what all their money goes to go
• Saves Face
  • Saves face for the women because they are still bringing in money and it will keep the peace between them and their husbands
  • Saves face for the cooperative because they are able to accomplish their goals and provide nutrients through the goods
• Implications of the relationships
  • Short term
    • Men in the family may be angry
    • Unrest within the family units
  • Long term
    • Hopefully the families get used to this way of compensation and relationships strengthen
• Implications of the venture
  • Short term:
    • The children receive more nutrients and are healthier
  • Long term
    • The venture will be achieving its duel goals
    • The children will get more resources and access to nutritional foods (the porridge)

Solution 3: Doing nothing

• Pros:
  • Not interfering in culture
  • Women are not necessarily opposed to men taking money anyway
  • Not putting women at risk since not taking money away from men
• Cons:
  • Men can still waste money
  • Children do not receive as much food
• Saves Face for the women and their husbands
  • The women do not have to disturb the family dynamic
    • the culture of this male dominance within the household is deep ingrained into a lot communities
    • going into a community and trying to rewire how their families and power dynamics work is not an okay thing to do (white saviorism)
    • therefore, although it is not ideal, doing nothing might be the right thing to do in a situation as delicate as this one
  • The husbands are not exposed for their irresponsible behaviors
• Implications of the relationships
  • Short term
    • There is no tension in relationships between men and women because the status quo is maintained
  • Long term
    • The issue could cause problems down the line as the children aren’t getting important resources like food and clothing.
• Implications of the venture
  • Short term
    • Venture still not achieving dual goals
  • Long term
    • The power dynamic within the family still probably would not be fixed

The best course of action is Solution 2: In addition to still paying the women regular wages, compensate for some of their wages in goods (i.e. food, personal care products). This solution addresses the issue at hand, but does not completely attempt to rewire the family dynamic. This solution benefits all the parties involved and saves face for all as well. To begin, the women themselves do not have to confront their husbands, but are also getting having their work go directly to getting the things they need for their children. The children, of course, are benefitting because they are ensured that some of their mother’s profit is going to them and their well-being. The men will be saved face because they won’t be directly exposed or confronted for their irresponsible behavior, but they still will have access to some money and will not take their anger out on the women. I (us, we) in this siutation will benefit because we are achieving better social outcomes for the venture and are achieving the twin outcomes desired. We will also be financially empowering women while having the children be fed nutritious foods.

Implications of this solution are that there will have to be a whole other section of the venture dedicated to organizing and implementing the distribution of these goods. This will be tricky and complicated at first to organize who gets what, how much, and when, but in the long run this will be an incredible solution. There may also be some anger from the male figure in families because they will not have access to all the money they had before. This could be something that the women’s cooperative talks about to the women beforehand with possible strategies to deal with this. However, the men cannot get directly angry at the women because they physically will not have the money, they will have the goods instead.

We also must consider impact of the venture on technological, social, economic and environmental effects. In terms of techonolgy, there may be a need to implement new technology, perhaps a computer system, to organize who gets what goods and what amount of money. Socially, this will have a really positive effect for the mothers and children and empower them to get what they need to help the family unit and not just satisfy the men. Environmentally, there will be little to no major impact.

Overall, this solution offers the most positives for all the parties involved.