To answer such complaints, Mulat staged latrine-building workshops in a few communities, with raffles. "The lucky winner got a latrine," Mulat said. Neighbors did the construction, using simple materials such as saplings and cornstalks. "Once people saw how the latrines worked and they started using them, they really liked them—especially the ladies." In this conservative region, women had been suffering for years because it was a cultural taboo for them to defecate in daylight, when they could be seen. "It brought shame and ridicule on your family," Mulat said. "They basically had to go to the bathroom at night, which could be very inconvenient."
With women leading the charge, latrine fervor soon swept the Amhara region, where more than 300,000 new household privies have been built since 2002, far beyond the 10,000 that health officials initially had in mind. Neighbors competed to see who could build the best one.
Having visited a few of those reeking city latrines the farmers complained about, it was with some trepidation that I made the half-hour hike down a broken boulder field, across a sluggish creek and up into the scrubby hills near Lake Tana to meet Wallegne Bizvayehu, a farmer who proudly showed me his family privy, one of 300 new sanitary facilities in his village of 6,000. It was a simple structure about ten feet deep and three feet wide, with airy walls of woven maize stalks and a slanting thatched roof lined with an orange plastic tarp. Wallegne's outhouse was a clean, odorless, well-swept building, with thin bars of sunlight shining through the walls, and not a fly in sight—an island of unaccustomed privacy in a village of barking dogs, farm chores and family obligations.
"Since we built it I believe we've been healthier," Wallegne said. "We've decreased our visits to the nurse's station." Inspired by Wallegne's example, three neighbors were building new latrines. "They'll build them themselves," Wallegne said, "but of course I will help if they need it."
This seemed to me the salient lesson of Jimmy Carter's efforts in Ethiopia, where Africans were helping Africans. The former president made the high-level contacts with prime ministers and health officials, then went home to raise the contributions. He gathered a small but talented technical staff in Atlanta to supervise and plan projects. But they remained largely invisible on the ground in Africa, where the recent history of charity has been written in overblown promises, unrealized dreams and squandered billions.
"Most of the money spent on foreign aid never gets to the suffering people," Carter told me. "It goes to the bureaucrats and to wasteful contractors. There's data showing that for every $100 in available aid for the control of disease and suffering in Africa, only $20 gets to the people who need it."
Determined to improve upon that record, Carter (a notoriously frugal child of the Great Depression) has kept his expenses low, infrastructure small, accounting systems rigorous and expectations reasonable. Over the past two and a half decades in Africa, he has been happy to take small steps, to build upon them and to let local people take credit for the programs that work. In Ethiopia, he has drafted respected professionals such as Teshome Gebre and Mulat Zerihun, who built their own network of indigenous helpers. These villagers were the ones who went to the markets and made the announcements of forthcoming clinics, kept the records, dispensed the medicine, trained the nurses and performed the eye surgeries.
"That is the key to success," said Carter. "We don't come in to impose something on a country. We get invited. We help. But all the work gets done by local people."
And now local people were fanning out to make sure the nets were properly deployed all over Ethiopia, which may yet win its long struggle with malaria.
Robert M. Poole is a contributing editor to Smithsonian. His "Lost Over Laos" appeared in August 2006. Trained as an artist, photographer Antonio Fiorente lives in Addis Ababa.