The puzzle of Wajir

These are dire times for those of us working in development cooperation—more dire still for millions of people who are the focus of our work. Since the onset of a new government in the United States—the beginning of the second Trump era in North American politics—the world has witnessed the consequences of treating development collaboration as a business proposition. It’s a time for cleaning out the proverbial attic and discarding the so-called ‘left-wing hobbies’ of the elite, no matter the human cost. This mentality is not confined to the US but is spreading closer to home, in the Netherlands, across Europe in Germany, France, Belgium, and the UK, and elsewhere across the globe. With the stroke of a pen and at an alarmingly rapid pace, millions of lives are being endangered, and global partnerships are being jeopardized. How can we counteract the devastating effects of budget cuts in critical development areas and the destruction of academic and professional collaborations in global and planetary health?

In these stormy times, during the political coup d’état by a few manipulative men in world politics, I read Frank Terwindt’s book The Puzzle of Wajir. It’s an account of someone who walked the path of development work, starting in the 1980s. It offers an honest reflection of his experiences in a world that, back then, looked quite different from the one we know now. The book is an instructive reflection on his work as a public health consultant, dealing with critical issues in development collaboration. The title itself – The Puzzle of Wajir – is intriguing. What exactly was the puzzle, and what pieces needed to be connected?

This review is structured in two parts, and followed by an epilogue book review and introduction to evoke a dialogue. In Part I, the author Frank Terwindt introduces his motivation for writing the book, in which he masterfully intertwines personal growth with critical reflections on the dynamics of development work. In Part II, I will summarize some key crossroads discussed in the book, which we explored in an interview.

Part I: Introduction by Frank Terwindt

“Although now retired, I am still fascinated by public health and the geopolitical context in which Development Cooperation (DC) is evolving. That’s what inspired me to write my book. I wanted to share my reflections about this important but complex domain with my compatriots. Using examples from my work experience, I explain how public health is directly linked to global challenges, such as the widening gap between rich and poor, environmental damage, climate change, and migration.

The reader may initially be disappointed by the lack of straightforward success stories in my book. By that, I mean effective, efficient, suitable and lasting solutions. But that’s the reality: the clichés about development cooperation, whether praising or condemning, do not take into account the many challenges these programmes face. Independent NGO projects and vertical programmes might report impressive results, but long-term, integrated development cooperation often encounters political conflicts, power games, and corruption. Despite this, I see development work as an ongoing learning process that is immensely valuable for all involved.

More than half a century ago, the Western world mostly engaged in missionary and humanitarian work, ‘to save the poor.’ Over time, we have learned that development cooperation can only yield lasting benefits for both parties if it is based on equivalent, respectful collaboration.

Recent developments in Dutch politics pose an acute threat to my country’s commitment to partnering with poor nations. Not only has the new government replaced the term ‘Development Cooperation’ with the outdated term ‘Development Aid’, but the national budget for this area has also been drastically reduced and is no longer linked to our gross national income. Furthermore, in line with neoliberal policies, it is intended that our international trade should benefit more from these development investments, while the co-financing of NGO work is being reduced by our government. Meanwhile, my country still continues to fulfil its commitments under the UN Sustainable Development Goals.

MTb of November 2024, focusing on Migrants and Health, reminded us of the goal of Universal Health Coverage: to enable access to healthcare services worldwide without causing financial hardship. Access to healthcare for migrants is still not guaranteed in the Netherlands, which seems symptomatic of our attitude toward immigrants. The government seems to think we can simply discourage refugees fleeing climate change, war, and poverty from crossing our borders. Reflecting on my time in these regions, I consider this policy naive and counterproductive. If we stop investing in development partnerships and lose contact with disadvantaged communities globally, I believe this will backfire on us. The world is too interconnected to ignore what happens in distant places. Our tradition of investing in development cooperation with poor countries has helped us understand global phenomena like migration.

In the epilogue of my book, I advocate for a less condescending and hypocritical Western approach to development cooperation for the benefit of our planet.”

Part II: What can we learn?

Let’s start at the beginning. I asked Frank Terwindt what motivated him to work in the field of public and global health for over three decades, and what continues to inspire him. For him, an interest in travel and a passion for justice were key motivations, along with his upbringing in a Catholic environment, and an uncle who served as a missionary priest in Congo. This broadened his perspective early on. In the first chapter, he questions whether he too can be considered “some sort of missionary” when he finds himself working for MSF in Mali. This reflection is nuanced and developed further throughout the book.

We continue by discussing the many assignments Frank undertook during his career. The table of contents provides a glimpse of this journey, reflecting his writing style and hinting at the content. Some chapters are titled “Letter from…” using his correspondence as a gateway to discuss his experiences in Yemen, Liberia, Benin, Congo, and Namibia. Other titles are more cryptic and evoke curiosity, such as “If it was an evil spirit I was supposed to know,” “Health in God’s name,” “Strategy in a dangerous environment” and “Mongolia, quo vadis?” These intriguing titles lead into discussions about his work as a public health consultant, his travels, and the dilemmas he faced.

Of the many topics we discussed, I’ll highlight some of the dilemmas Frank encountered—dilemmas that are still relevant today, especially in light of the current political climate and shifting dynamics on the global stage.

Humanitarian work or structural development?

In the chapter “From Humanitarian to Development”, he discusses how, in 1986, what began as humanitarian assistance in Nepal evolved into a sustainable part of the country’s health care system. Key elements? A political revolt, combined with a belief in community-based rehabilitation and preventive care. Frank contrasts this with his experiences working in Uganda, in the 1980s, in what was then considered ‘The Pearl of Africa’. Rebels were fighting against dictator Obote, while MSF provided emergency medical care, staying neutral to continue its work. At one point, authorities banned the provision of medicines, fearing they might fall into the hands of rebels. As the situation worsened, MSF had to leave, and only Catholic missionaries continued their work. For Frank, working as a country coordinator, the work became increasingly challenging. He realised that leading in crisis situations required a different kind of mindset – you have to make decisions quickly, often with limited information. Besides emergency work, the teams were also facing public health issues, which led to differing opinions within the team about priorities and aid strategies. Some team members believed they should immediately deploy mobile units to the refugee camps, while others argued that it was more important to start with an assessment of the most urgent (health) needs. There were also tough questions around how to treat tuberculosis in a context where people are constantly on the move, fleeing violence and instability. It was then and there that Frank decided to shift his focus to public health—a vital field dedicated to improving and protecting the health of communities and populations both locally and globally and striving for equitable access to essential resources

Do they know it’s Christmas?

A few years after the world was being urged to donate money for the famine in Ethiopia – through the now highly controversial charity song [1] – Professor Maurice King stood before his students in Heidelberg, Germany and posed a provocative question: What are we doing? Are we simply providing aid to countries that, economically, cannot support their citizens? Is humanitarian aid nothing more than a band-aid—one that overlooks structural deficiencies and risks perpetuating suffering by failing to address root causes? King challenged the students to critically examine the role of the West in emergency and healthcare programmes in so-called “poor countries.” Which countries are labelled poor, and why? Many of them are, in fact, rich in natural resources, which in many places cause conflict and rarely benefit the population, but rather a select few who control them. His words sent shockwaves through the room. What is this? Do you see us as playing God? Don’t we have a responsibility – a debt – to the countries we colonised? For Frank, engaging with this dilemma was eye-opening. It marked the beginning of a lifelong interest in historical patterns and the importance of understanding problems within their full context. That reflection continues to this day, as we are faced with ongoing structural conflicts and the broader planetary crisis fuelled by climate change. One can only wonder how Maurice King would respond to today’s dilemmas, where emergency aid is given instead of support for long-term development and systemic changes.

‘Snail mail’ and the ‘The game and the players’

It’s a strange feeling, reading the chapters on USAID, the World Bank and the World Health Organisation during a time when they all are under siege by the Trump administration—curtailed in funding and ridiculed for their missions by the billionaires and autocrats that are shaping global politics now. For Frank, his visit to the USAID offices in Liberia – tucked inside the massive concrete fortress of the U.S. Embassy – left him with mixed emotions. Entering the building and passing through tight security regulations was no small feat. Even something as simple as sending a letter to a colleague within that building could take ages, delivered at a pace that felt almost symbolic – ‘by snail’. The staff inside often carried a quiet sense of apology for the heavy bureaucratic machinery they had to navigate each day. In many ways, the complexity of the building mirrored the complexity of development cooperation, the work on the ground itself: navigating layers of policies, politics and procedures, and full of contradictions.

The chapter The game and the players continues along this line of thought. Reflecting on his own work and that of his colleagues – both in donor and recipient countries – Frank compared it to a stage play, where each participant knows his role, which, shaped over time by politics and competing interests, almost seem predetermined. A perhaps cynical observation follows, but one that seemed to be true in a number of assignments he had worked on. For example, his experience in Mali, where he collaborated with the national team on strengthening the country’s health system. Although all partners were genuinely committed to the shared goal, translating intentions into practice proved far more difficult. Cultural, political, and economic differences, divergent administrative systems and protocols, and external pressures (for example conflict or trade protection measures) often obstructed meaningful cooperation in many bilateral and multilateral aid efforts. Frank weighed the advantages and disadvantages of investing in smaller-scale initiatives, bypassing governmental systems – often bureaucratic and coloured by politics. While this approach may seem attractive, especially in the short term, he recalled the reasoning for evolving to the current day approach of collaboration and co-creation, grounded in mutual respect and equality.

How to solve the puzzle of Wajir

Reading Terwindt’s book and recalling both the success stories—like the establishment of the community care centres in Mali, which eventually became fully integrated into and run by the community—and the many challenges and dilemmas he faced along the way, I think about the many lessons to be learned. Our ability, or willingness, to learn them is often limited by the circumstances we work in, or by the need to swim against the current in an increasingly politicised environment. Funding cuts in development cooperation and the curtailing of academic research and international collaboration are just a few examples of how our work is continually being reshaped.

Yet, books like The Puzzle of Wajir are essential. They help us reflect critically on core issues in our field, like the business approach and the win-win paradigm, the revival of health initiatives by and for the people, the ethical complexities of social marketing strategies, and much more.

As Frank reflects on his long career in development cooperation, one thing becomes clear: the puzzles of global health and development are complex, interconnected, and never fully solved. His book offers valuable insights for anyone involved in or curious about this field -especially at a time when we are confronted with an increasingly turbulent political and environmental landscape. Whether you’re a global health student or professional, or simply interested in understanding the particulars of development work, The Puzzle of Wajir is a compelling read.

The final chapters take a forward-looking turn, as Frank recalls Lords of Poverty, Graham Hancock’s searing critique of the aid industry. Written in 1989, during the height of generous public spending on aid projects and the heyday of the World Bank and IMF’s structural adjustment programmes, it exposed how these institutions pushed countries into sweeping reforms in exchange for loans, often with lasting and painful consequences.

So many of those lessons were already on the table back then. Why didn’t we learn them? They were relevant then, and they remain just as relevant now. In the closing pages, Terwindt poses a deeply personal question: if he had to choose between saving humanity or saving the planet, what would his choice be?

You’ll find his answer on the final page of the book.

References

1. The charity song ‘Do They Know It’s Christmas?’ was written in 1984 to raise money for the 1983-1985 famine in Ethiopia. The song was inspired by a series of reports made by a BBC journalist, drawing attention to the famine in Ethiopia describing it as ‘a biblical famine in the 20th century’ and ‘the closest thing to hell on Earth’. While the song is still being rerecorded, it remains highly controversial, not in the least for its racist lyrics, promoting stereotypes and overall for being condescending.