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? 

Step 1: Determine the facts in the situation – obtain all of the unbiased facts possible 

• ~35% of the children in East Africa is stunted due to poor nutrition
• The current gruel used to complement breastfeeding is not nutritionally adequate according to scientific research, but the moms believe the gruel is nutritious.
• WHO recommends breastfeeding until an infant turns 6 months
• The longer the child nurses when the mother is HIV+, the higher the chance of them contracted with HIV.
• The donor who gave us the grant intent is to build up the women’s cooperative to simultaneously improve the nutritional status of children and improve the livelihoods of rural households
• The grant has sufficient funds for a nutritious, shelf-stable porridge made from locally grown produce
• The porridge is intended to wean children off of breastfeeding at the age of 6 months
• The 500 women are skeptical of the porridge as a weaning food because it is too new (not something they’re accustomed to in their daily lives)
• Pesticides are typically used in growing the crops used in the porridge
• Assumption: not all women are aware of the adverse health effects resulting from the pesticides used in the crops to make the porridge
• The area has a high prevalence of HIV/AIDS and very little testing

Ethical issue: Currently, mothers in the region combine breastfeeding with a non-nutritious maize and banana gruel for the first 24 months of their child’s life. HIV/AIDS is highly prevalent in this region, is not tested on a widespread scale, and can be transmitted through breastfeeding. Our job is to establish a cooperative that will work to give mothers a nutritional porridge that they can use to wean their children off of breastmilk at around 6 months. The problem is, some of the ingredients in this porridge are grown using pesticides, which could result in pesticide residues in the porridge itself. The ethical issue here is deciding whether to go ahead and feed these 6 month old children pesticide grown food, or to continue having the mothers feed their children breast milk with the risk of transmitting HIV.

Step 2 & 3: Define the stakeholders – those with a vested interest in the outcome. Determine and distinguish between the personal and professional motivations of the stakeholders.

Stakeholders:

• Breastfeeding Moms:
  • Professional Motivation: N/a 
  • Personal Motivation: The mothers want to be providing their babies with the best nutrients while keeping them safe 
• Woman joining the co-op
  • Professional Motivation: sell as much porridge as possible to the community (build up the co-op), make the best and safest product (porridge), educate breastfeeding mothers, make money.
  • Personal Motivation: help their own babies stay healthy, help their neighbors.
• Babies
  • Professional Motivation: N/a 
  • Personal Motivation: Want to minimize their risk of contracting HIV and still intake their required nutrients.
• Farmers 
  • Professional Motivation: produce as much of their crop for community consumption as possible, make money (maximize profit), collaborate with the women in the cooperative 
  • Personal Motivation: help the community stay healthy (provide the best crops)
• Grant Donor (secondary stakeholder)
  • Professional Motivation: Have good reputation of making good deeds, want their money to be allocated wisely and productively for meaningful purposes
  • Personal Motivation: Want  women in the area to be healthier and have their livelihood improved
• Doctors
  • Professional Motivation: Would want HIV cases to go down and  would want to allocate their resources and knowledge to other patients with other illnesses  
  • Personal Motivation: Prevent the amount of infants they see with HIV/Malnutrition
• Us (researchers establishing the co-op)
  • Professional Motivation: To start a successful and sustainable co-op what will also enhance our skill sets and credibility, build up good record and establish their credibility for future fundings and resources 
  • Personal Motivation: Want to improve the livelihoods of women and children in the arena 

Step 4: Formulate (at least three) alternative solutions – based on information available, to have a win-win situation for your relationship and your venture.

Potential solution 1: Form the cooperative. Educate the mothers the dangers of breastfeeding children while being HIV+. After six months, have them wean their children off breastmilk with the porridge (without telling them the potential harms from the pesticides).

 Ethical Principle or code: Consequence-Based Thinking because we will be able to convince more women to use the porridge by not telling them about possible harms of pesticides. By “hiding” some negatives we will be able to stop breastfeeding earlier and prevent more cases of HIV in children.

Pros: 

• The babies will have a smaller chance of contracting HIV from their mothers
• Moms are more likely to switch to the porridge if they think that it is more nutritious than the cruel without any side effects. 

Cons: 

• We are not telling the mother about the negative effects of the pesticides in the porridge so there is a chance that the porridge will affect the babies negatively in some way.
• It is also unethical for researchers to not inform women the side effects of the porridge that was developed specifically for their children.
• HIV+ education to the women and locals cost time and resources 

Potential solution 2: Form the cooperative to educate the Mothers the dangers of breastfeeding children while being HIV+. After six months, have them wean their children off breastmilk with the porridge, and tell them the potential harms from the pesticides.

Ethical Principle or code: Duty Based Thinking because we are doing the right thing, and most ethic thing by giving the women ALL the facts we have. We are telling them all the positives and negatives of breastfeeding and the porridge.

 Pros: 

• Mothers understand the dangers of HIV transmission through breastfeeding
  • Reduces the number of children with HIV
• Mothers know when to begin feeding their children the porridge, the potential harms, and the nutritional benefits of the porridge
  • Reduces Malnutrition

Cons

• The decisions now depend on the mothers’ intuition, which can go either way
• The children still face the risk of contracting HIV+
• The children are now at risk (if their mothers use the porridge) to the harms of pesticide residue in the food they consume

Potential solution 3: Form the cooperative to educate the Mothers the dangers of breastfeeding children while being HIV+. After six months, have them wean their children off breastmilk with the porridge that has gruel in the recipe, and tell them the potential harms from the pesticides.

Ethical Principle or code: Duty Based Thinking (for same reason as above) + Care Based Thinking because we are taking into account the personal relations with the women who prefer to use the guel and feel comfortable with it. 

 Pros:

• The mothers will be more comfortable using an ingredient they trust in their new food supplement
• the risk of the babies contracting HIV will reduce

Cons:

• The mothers might be hesitant because there is still a risk associated with using the porridge.
• Adding gruel to the recipe might reduce the nutritional values of the original recipe, which might impose negative implications on the children’s growth and development. 

Step 5: Seek additional assistance, as appropriate – engineering codes of ethics, previous cases, peers, reliance on personal experience, inner reflection.

• There is a 15-45% chance of passing HIV onto your baby if neither are taking treatment (https://www.avert.org/hiv-transmission-prevention/pregnancy-childbirth-breastfeeding) 
• In East and South Africa, 20.7million adults have HIV in 2019
  • 84k new HIV infections in children (0-14yrs) in 2018
  • (https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/overview)

Step 6: Select the best course of action – that which satisfies the highest core ethical values. Explain reasoning and justify. Discuss your stance vis-a-vis other approaches discussed in the class.

• Solution number 3 is ideal because unlike solution one and two it incorporates an ingredient into their children’s diet that they are comfortable with
• Solution number three also allows the mothers to be aware if the downsides of this porridge
• Although Solution one would allow for the least amount of push back from the mothers when encouraging them to use porridge it is not ethical
• Solution 2 allows for the most push back from the mothers because it tells them the dangers of using the porridge and does not include any known ingredients that they like to feed their babies therefore it is the least appealing option
• Ultimately, solution three allows for the least amount of push back in an ethical way making it the ideal solution

Step 7: (If applicable) What are the implications of your solution on the venture. Explain the impact of your proposed solution on the venture’s technology, economic, social and environmental aspects.

• Socially this venture would allow for a healthier community/families as the chance of their babies contracting HIV would decrease
• It will also allow for the mother to build a community with other mothers
•  a sense of community could also be built between the local farmers, mothers, and the researchers
• Environmentally there could be a higher demand for the crops they locally grow which means more pesticides will be used which is bad for the environment as they wash into water streams
• Economically the farmers could see and increase in their profits due to more mothers using the porridge
• Economically it will allow for the community of mothers to generate funds to help support their families and feed their children
• It will also allow for them to out money back into their harvesting and cooking tactics which would allow for a technological increase

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? 

Step 1: Determine the facts in the situation – obtain all of the unbiased facts possible 

• The cooperative has been thriving for 6 months
• The women can sell the produce grown on their farm to the cooperative for additional income.
• The women work for nine hours a day and make 3$ 
• The women like this arrangement because it saves them money and time 
• The women enjoy working together and are happy with the co-op
• The women have to give their money to their husband father or brother
• The money the women make gets wasted on alcohol/frivolous things
• The twin social outcomes of improving the nutritional status of children and the livelihoods of rural households are not achievable right now
• You as the entrepreneur will leave the cooperative’s committee (you and other 6 local women) after 6 months. 
• The entrepreneur does not have direct say in the in the co-ops functioning
• Assumption: not all 500 women of the cooperative will work on growing the produce.
• The women are upset that their hard earned money is not used to feed their children

Ethical issue:  Although the cooperative is thriving the goals of the cooperative are not being met because the women are loosing their hard-earned money to the men in their household when they return home from work. The women are upset because they wish their money would be allocated to feeding their family instead of on frivolous things. Therefore you as the entrepreneur cannot truly say your co-op is thriving until it is reaching its original goals and the money issue is addressed. 

Step 2 &3: Define the problem and the stakeholders – those with a vested interest in the outcome. Determine and distinguish between the personal and professional motivations of the stakeholders. 

Problem: The women in the co-op do not get to keep their money to feed their children, because the money is given to the men in the household. You are leaving the co-op in 6 months and want to get the cooperative back on track. You want to get the cooperative on track of achieving the twin social outcomes in a sustainable manner.

Stakeholders:

• Other 6 members of leadership committee
  • Personal Motivations: want to provide for their family, wants to keep good relations with the men and not cause issues, wants to keep good relations with the other women in the co-op. 
  • Professional Motivations: maintain position on the leadership committee, make a decision that satisfies everyone in the co-op and in the community.
• Men in households:
  • Personal Motivations: buy products and goods that are personally satisfying (alcohol, and luxury items)
  • Professional Motivations: Work and provide for their family, but also take the money that the women bring home.
• Breastfeeding Moms:
  • Professional Motivation: N/a 
  • Personal Motivation: The mothers want to be providing their babies with the best nutrients while keeping them safe 
• Woman joining the co-op
  • Professional Motivation: sell as much porridge as possible to the community (build up the co-op), make the best and safest product (porridge), educate breastfeeding mothers, make money.
  • Personal Motivation: help their own babies stay healthy, help their neighbors.
• Babies
  • Professional Motivation: N/a 
  • Personal Motivation: Want to minimize their risk of contracting HIV and still intake their required nutrients.
• Farmers 
  • Professional Motivation: produce as much of their crop for community consumption as possible, make money (maximize profit), collaborate with the women in the cooperative 
  • Personal Motivation: help the community stay healthy (provide the best crops)
• Grant Donor (secondary stakeholder)
  • Professional Motivation: Have good reputation of making good deeds, want their money to be allocated wisely and productively for meaningful purposes
  • Personal Motivation: Want  women in the area to be healthier and have their livelihood improved
• Doctors
  • Professional Motivation: Would want HIV cases to go down and  would want to allocate their resources and knowledge to other patients with other illnesses  
  • Personal Motivation: Prevent the amount of infants they see with HIV/Malnutrition
• Us (researchers establishing the co-op)
  • Professional Motivation: To start a successful and sustainable co-op what will also enhance our skill sets and credibility, build up good record and establish their credibility for future funding and resources 
  • Personal Motivation: Want to improve the livelihoods of women and children in the arena 

Step 4: Formulate ONE solution – based on information available, to have a win-win situation for your relationship and your venture. Approaches [1/2/3: repeat for every action] 

Optimal Solution: The cooperative will establish a partial credit system that allows women to earn more benefits by storing some of their earned money rather than cashing out $3 every day. These benefits can be in the form of discounts on local goods and porridge for the kids.The committee will decide the procedure on how to cash out (limit per day, what products can be purchased with high credits), making sure that money will be spent towards their kids rather than being wasted by the men in the households. However, the other portion of their pay (lesser part) will be in cash so that they can still save face with the men in the households. Additionally, the women will also be allowed to take home roughly two servings of porridge each day to ensure their kids are being fed.

How does the solution meet twin outcomes?

The women in the co-op will be able to use their pay to provide for their families now (through the credit system), and also will still be bringing back physical money to the men at home (so it doesn’t disrupt cultural norms and cause issues in the community). The women will not have to confront the men about wanting to use the money for other non-frivolous things. On the other side, you are still “paying” the women in the co-op. Altogether, this solution will help meet the twin outcomes: better nutrition for the children and improved livelihood for rural households.

Pros: 

• The women have to spend a certain amount of their earned pay on food for their families. 
• The women are allowed to bring home porridge free of charge each day to nourish their children.

Cons:

• The men will still be receiving some of the women’s pay and using on personal luxury items.
• The women will only be able to use their credit earnings on porridge, or food/products that are within the co-op (or agreed upon by the committee). 

How does it save face of those involved? 

The co-op partial credit system allows for the women to still bring home a smaller portion of physical money that the men will be able to spend how they want to. The women will now be given an opportunity to spend their money how they want (on their families) without having to confront the men. It will also save face for the co-op and the committee, because it is a very non-confrontational approach that attempts not to disrupt cultural norms. 

Implications on relationships 

• Short-term 
  • The men will most likely be disappointed that the women are bringing home less money, but the men will not likely be too offended that they abuse the wives and the children because at least we still give them the impression that they are “in control” of the finance.
• Long-term 
  • The relationships will be healthier between the men and women in the household because the men will still be receiving money though it is small and the women will be able to feed their children
  • The men might start changing their behavior and thinking more about their family.
  • The families will have access to more food and necessary items (live better)
  • If the children grow up happier and healthier, they could help out the family with higher productivity, which could raise the family’s income and contribute to the elevated livelihoods.

Implications on the venture 

• Short-term
  • They co-op will have to be prepared to have more porridge available because the women in the co-op will now be buying more too.
  • Might be easier to pay the women (not need as much cash).
• Long-term 
  • The committee will now have more power in deciding the ratio of credit to cash payments of the women, and also in what products they can use the credit on.
  • The co-op may be more successful because each of the women will now essentially be reinvesting their earnings into the company by buying food. 
    • More women may be able to participate

Seek additional assistance, as appropriate – previous cases, peers, reliance on personal experience, inner reflection 

We combined our own proposed solution as well as our peers’ in order to maximize the benefits to the community while saving faces for every stakeholder involved. Some of our peer’s suggestions:

1. Gift card. Extracting part of the money that they earn per day to the gift card, which can be used to purchase goods in the grocery store. 
2. Food Receipt. Require that a certain amount of the food is spent responsibly. Receipts required, incentives could be included to encourage more responsible use of money in the rural household.
3. Hold meetings with the cooperative’s committees (6 women) and the community leaders (including both men and women) to bring up the issue and discuss how money earned by the women working for the cooperatives can be distributed in a more sustainable manner. 
4. Co-op gives the women option to walk away with porridge everyday for free to address malnutrition problem

Our inner reflection: 

• We do not integrate solution 1 and 2 into our proposal because we think it might not be as effective as the credit system in the context of giving  the power to the women to purchase food and necessities to support their families physically and mentally. 
• We got solution 4 from our peers, and we think it is a viable idea that can help address the malnutrition problem effectively; so, we incorporate them into our solution. 
• For solution 3, it doesn’t not necessarily solve the problem, but it reminds us that no matter how good our solution is, if we don’t have a good implementation strategy, it automatically becomes useless. The team will take this into consideration into our last step.

Step 7: List the sequence of actions you will take to implement your solution.

• Ask the women in the leadership committee if they want a change. Get them to understand the system and the problem we are facing.
• Validate it with committee and the men – talk to 25-30 people one on one, try to get them on board 
• Bring everyone together for the large meeting
• Try to moderate the discussion → move it towards to the grassroot diplomacy 
• Ask the people in the meeting, “How do they want to structure the cooperatives’ finance?”
• Figure out a set ratio of credit/cash pay, and implement ways the committee can adjust this over time if it doesn’t work.
• Figure out what items the credit can be used for.
• Test the system out for a few months, and reconvene with the committee to make adjustments if needed. 
• Before you leave, make sure you communicate candidly and clearly with the 6 women in the committee about the vision and core mission of the cooperative, making sure everyone is on the same page. Encourage them to find and educate younger members about the mindset so that the venture keeps flourishing even after your departure.