PART ONE

STEP 1: Facts

• We’ve received a grant to establish a cooperative in East Africa
• ~35% of children in this area have stunted growth due to malnutrition
• Mothers typically feed infants a gruel made of maize and bananas starting at ~2 months to supplement breastfeeding. This gruel is missing some key nutrients
  • WHO recommends children are exclusively breastfed up to 6 months of age
• HIV/AIDS is very prevalent in the region
  • Testing is rare and not readily available
• The longer an infant breastfeeds, the higher the risk of HIV transmission to the child (If the mother is HIV+)
  • Testing is still scarce, so many with HIV don’t know they have it
• We aim to replace the gruel with a shelf-stable nutritious porridge that will meet all the nutritional requirements and will be made from locally grown produce
  • Many of the crops are grown with pesticides
  • Mothers are skeptical of the use of the porridge
• Porridge aims to wean children off breastmilk at 6 months of age
• There is a high number of women (500) interested in the cooperative’s porridge idea 

Ethical Dilemma- finding the balance between either feeding the kids food grown with pesticides or increasing their likelihood of contracting HIV due to prolonged breastfeeding

• Are both problems of the same magnitude?
  1. Most women breastfeed until at least 2 years
  2. How bad is HIV in the long term? How bad is exposure to pesticides?
• Leverage points – 6 mos vs 2 yrs

STEP 2/3: Stakeholders and Motivations

• Entrepreneur/Researcher
  • Professional
    • Good publicity and credibility
    • Build up a track record of successful projects
  • Personal
    • Aiding the decrease of stunted growth rates
    • Improving the nutritional status of the children
    • Support livelihoods of the mothers
• Children (secondary)
  • Too young to have independent motivations; desires reflected in the motivations of their mothers
• Donor (secondary)
  • Professional
    • Recognition/ Good publicity
  • Personal
    • Improve nutritional status of children
    • Improve livelihoods of rural households
• Government (secondary)
  • Professional
    • Reduce prevalence of HIV by preventing transmission from mothers to children
    • Improve health of population by giving children access to proper nutrients from infancy, reduce stunting rates
    • Promote agricultural biodiversity and the development of value chains for produce
• Women/Mothers
  • Professional
    • Want to improve their livelihoods without risking the health of their child
    • Increased income
  • Personal
    • Want to source food that is pesticide free / safe to consume for their infants
    • Want to stick to traditional breastfeeding practices they are comfortable with
    • Reduce risk of HIV transmission to their children
• Farmers
  • Professional
    • A good work opportunity/ paycheck
  • Personal
    • Helping out their community

STEP 4: Solutions

• Introduce this porridge options as a supplement for the mothers, assuming that better nutrition for the mother will be carried over to the child as well.
  1. Ethical Principle
     1. Beneficence – Attempting to reduce harm potential by asking the mother to consume the porridge because pesticides are less harmful to adults because they have a larger body mass 
     2. Non maleficence – balancing risks and benefits of promoting the new porridge that may increase exposure to pesticides with reducing risk of potential HIV transmission.
  2. Pros
     • The amount of potential pesticide contaminants consumed by the child will be reduced because the mother is directly consuming the porridge
     • The child will still receive proper nutrition and supplement as the mother’s diet is improved
     • This prolongs the amount of time that the mother can breastfeed, so the child can be weaned on they have grown more and are less susceptible to harmful pesticides
  3. Cons
     • The pesticides will still be present in the porridge
     • Mothers may still be reluctant to eat the porridge
     • Longer breastfeeding increases the risk for HIV

• Involve community health workers, local religious leaders to establish trust and educate women in a culturally-appropriate manner. Use package labelling to include important information as well.
  • Ethical Principle
    • Autonomy – we are providing the information they need to make an informed decision. We are involving key community members to help inform our venture and provide information in a culturally appropriate way 
  • Pros
    • They help validate our intentions and can communicate to women better about our project
    • Parents receive the information they need to make an informed decision about risks of both options (i.e., HIV transmission vs. pesticide exposure)
    • Community health workers can teach about nutrition and how it impacts child development
  • Cons
    • There might not be a community health worker/ leader
    • The porridge may cause worse issues for the children
    • Despite being informed, may stick to traditional breastfeeding practices
    • Additional financial costs that were not originally planned for 
  • Recommend that the gruel is introduced in small quantities until the child reaches a developmental stage that minimizes risks associated with pesticide exposure but does not increase the risk of HIV transmission. This leverages the window typical for breastfeeding.
    • Ethical Principle
      • Non-Maleficence – 
    • Pros
      • Reducing stunted growth rates and exposure of HIV
      • Takes into consideration that women typically breastfeed anytime up to two years. The WHO recommends breastfeeding until 6 months, so that leaves a large window to introduce this porridge.
    • Cons
      • This does not eliminate the risk of HIV transmission to the baby and does not guarantee perfect nutrition for the child.

STEP 5: Additional Assistance

While the WHO recommends breastfeeding until at least 6 months, it will be important to read the other recommendations. More research would also be helpful in weighing the risks from pesticides to the risks of HIV transfer to the baby.

STEP 6: Best Solution

The most ethical solution, in my opinion, is to give the women all the proper information and ultimately allow them to make the decision themselves. Breastfeeding is a personal and intimate relationship between the mother and her child, so ultimately allowing the woman to make the best choice for herself and her child seems best. The risks of transmitting HIV through breastmilk and the risks of pesticide exposure to young children may not be known, so relying on community health workers and proper labelling the porridge will be critical to properly informing the mothers. The risks of pesticide exposure may be reduced if the mother consumes the porridge, which will still ensure proper nutrition of her child; however, this does not reduce the risk of HIV transmission. Alternatively, the mother may choose to wait until the child is six months old and completely switch to porridge because she weighs the risk of HIV more heavily. Permanent developmental issues may result from pesticide exposure, but there are known treatments to lessen the impact of HIV. Assuming these treatments are not yet widely accessible, it is best to properly inform the mother and allow her to make the choice she is most comfortable with. It is likely that this method will not be effective in addressing either risk in it’s entirely, but it gives the mother the proper information to weigh all the benefits and risks herself.

STEP 7: Impact on Venture

The economic cost to the venture will be low if education is the only real action taken. Printing information on the product itself will be very low cost because a label is already necessary. Partnering with community health workers will have a higher associated monetary cost but may be more effective. Providing information instead of providing specific recommendations may eliminate some legal risk from the venture if a child is harmed by pesticide residues in the product because the porridge is introduced at too early a developmental stage. There are not really any environmental implications for the venture, unless they were somehow able to convince all the farmers in the region to switch to organic farming, eliminating pesticides all together; this is unrealistic.

PART TWO:

STEP 1: Facts

• Cooperative is thriving six months after launch
• Women working for nine hours a day earning KES 300 ($3)
• Women have opportunity to sell their produce to the cooperative at the prevailing market rate
• Cooperative gives the women a strong sense of community and identity, so they are happy
• Women are forced to turn over income to husbands, brothers, or fathers who spend it on alcohol and frivolous things
• This upsets the women because they want to use the money to feed their children
• As entrepreneur, one of seven members on leadership committee that oversees operations
• Committee is elected annually, and after six months, you practically leave entirely
• Other six members are local women who want things to change, but are not necessarily upset that the men are taking their money 

STEP 2/3: Stakeholders and Motivations

• Entrepreneur
  • Professional
    • To see success of business
    • To build good publicity for the venture
  • Personal
    • To see the women happy and their hard-earned money being used to feed their children
  • Women/Mothers
    • Professional
      • To improve their livelihoods by earning a wage
    • Personal
      • To provide proper nutrition for their children
      • To enjoy the community of the cooperative
    • Men
      • Personal
        • Maintain the status quo; having access to the wages the women bring home
        • Have money to spend on “alcohol and frivolous things”
      • Women on the Counsel
        • Professional
          • Keep the cooperative running smoothly
          • Make decisions beneficial for all members of the cooperative and community
        • Personal
          • Make sure the women all have money to feed their children

STEP 4/5/6: Best Solution

In my opinion, the best solution is to provide the women with 1/3 of their daily wage in cash to take home each day, along with a few servings of porridge. The other 2/3 of the earnings will be kept as equity in the cooperative, allowing it to grow and expand. This opens the potential for the opening a store owned/run by the cooperative that would reduce the distance that needs to be walked to the nearest market. After the women have earned some amount of money ($100 or so), they would be allowed to cash out. Alternatively, they could use their earnings to make purchases in the cooperative store at a discounted rate. This solution addressed the motivations of all stakeholders. The women are able to feed their children because they are provided with appropriate servings of porridge each day. The status quo is maintained, so the men will still see a portion of the earnings every day. This allows the men to make purchases of their choosing, maintain their social status, and will lower the likelihood that women experience domestic violence because they are not providing. There are some downsides because it is possible that the men will be upset that they are not seeing the full wage immediately. Even after the women cash out their money, it is possible that the men will still spend all of it on unnecessary purchases, but a larger lump sum decreases this likelihood. All parties are able to save face because no great societal upheaval is occurring, and a new exciting store will be introduced which will be positive for the community. It will be important to consult community leaders and ask the men for input to determine the specifics of the plans, ensuring that all parties are satisfied and willing to cooperate. In the long term, the mission of the venture will be achieved with this strategy. It is a sustainable model that will achieve the twin outcomes identified as goals of the venture because the women will be able to feed their children, but the habits of the men will not be upended. 

STEP 7: Step-by-Step

• Convene the council to discuss a strategy for expanding the cooperative using equity built by members, potentially building a store.
• Present the strategy to the women in the cooperative, asking for feedback and suggestions for change. Make sure their primary need, feeding their children, will be met.
• Once the women are on board, hold a larger town meeting. Present the change as a strategy to build a store, which will be closer than the market and sell alcohol for the men. Explain that in order to grow the cooperative, some wages will have to be withheld daily, but a portion will still be sent home along with porridge.
• Offer the men an opportunity to get involved in the cooperative by doing some of the traditional male labor. This will be essential to build the store. The men will then have some of their own wage and credits to be used in the store, like the women.