in development

Scaling SMS for healthcare.

2010-05-24T18:57:04+03:00

There is certainly no shortage of coverage of the mobile revolution in Africa. Mobile phones have undoubtedly ushered in a new era of amazing innovation and, more importantly, access to Africa. They've brought financial services to millions of unbanked Kenyans, empowered citizens to take an active role in promoting social change, supported humanitarians responding to crises, helped epidemiologists control disease outbreaks, and the list goes on. The mobile phenomenon is so well established that the initial enthusiasm of early adopters is now giving way to more constructive criticism. Which is not to say that we've exhausted our collective imagination on how to put this platform to use for the developing world. Indeed, there are endless opportunities to use mobile technology to support health, financial, education, agriculture, and governance sectors in Africa. But more importantly, many of these innovations have yet to reach their full potential. With the exemption of Safaricom's mobile money transfer service, M-PESA and now, M-KESHO, the majority of the mobile innovations you've probably read about are only reaching a minority population. The time for scaling mobile services has come. And I can think of no better place to start scaling mobile innovations in the healthcare sector than one of Sub-Saharan Africa's largest HIV/AIDS control programs - AMPATH.

First, a bit about the region in reference here - western Kenya. At 300 kilometers west of Nairobi we're a world away from the shiny towers of Safaricom and burgeoning tech community of Nairobi. This is a predominantly rural region where maize, malnutrition, and election fueled malevolence reign supreme. Nonetheless, nearly 50% of the population we serve owns a mobile phone. And since phone sharing is very common in these parts, nearly everyone has access to a mobile phone. But upon arriving here a year ago I was surprised to learn that relatively little has been done to utilize the ubiquity of mobile phones and the affordability of SMS text messaging to improve patient care. From conversations with colleagues across Kenya, I learned that our program is no exception. It seems that despite the fever pitch of the blogosphere, the reality on the ground is that SMS is widely revered as a potential communication channel for healthcare but, on the whole, it is still rather rarely deployed.

There are loads of opportunities to utilize SMS in healthcare. Personally, I'm most interested in patient facing interventions. Programs that help nudge people towards healthy behaviors. I just finished my third concept paper and pilot program design for such patient facing SMS interventions here at AMPATH. All three rely on open-source and elegantly simple software from Frontline:SMS. And all three could be easily adopted and implemented at other healthcare facilities. All you need is a mobile phone, netbook, and mobile signal (the latter of which is suprisingly ubiquitous across much of the continent). Assuming these pilots prove effective, we plan to swiftly scale these services to reach the entire population they are designed for.

Outreach:SMS. AMPATH now has over 100,000 HIV-positive patients enrolled into care. And with our current door-to-door HIV counseling and testing campaign these numbers are expected to increase exponentially over the next 12-24 months. Like all HIV programs, appointment adherence is critical to our ability to maintain the health of our patients and minimize their ability to transmit the virus to others. But with nearly 1 in 3 of our patients not attending clinic within a 10 day window of their scheduled appointment there's clearly considerable room for improvement. Our Outreach:SMS program aims to reduce the rate of missed visits by sending patients appointment reminders via text message. Big thanks to @bikobiko and @dalezak for developing the ReminderManager plug-in for Frontline:SMS (this nifty feature will significantly reduce the staff time required to operate the program). Reminders will be sent two days and one day before the patient's scheduled appointment to help address common reasons for missed visits - forgetfulness and failure to plan ahead. The objective of our program is two-fold: 1) maintain the health of our patients through improved appointment attendance and 2) reduce current program costs associated with follow up on patients who fail to attend clinic. And here's the kicker, this intervention will result in an overall cost savings for our program if it is able to reduce the number of monthly missed visits by 30% or more (which studies have shown is eminently feasible).

SMS for Heart Health: While much of Africa is overwhelmed by efforts to control infectious and nutritional diseases, non-communicable chronic diseases like heart disease are emerging as the next major threat to global health. Aggressive action is now needed to test, treat, and educate our patient population before yet another epidemic takes hold. We are about to begin an ambitious program incorporating hypertension screening into our door-to-door HIV counseling and testing campaign. All people identified with systolic blood pressure (SBP) over 160 will be put on hypertension drugs. People with SBP between 140-159 are given six months to change their lifestyle to try to self-regulate their blood pressure before they are started on drugs. This six month window offers us the greatest chance at an affordable means of preventing heart disease. But promoting behavior change requires frequent and consistent support - far more than what occasional clinic encounters can offer. We plan to use SMS text messaging to routinely educate this particular patient cohort on heart healthy habits and facts about heart disease to encourage them to make the lifestyle changes required to reduce their risk for heart disease.

SMS for ANC: This program is a blatant rip-off of text4baby. Text4baby was launched in the U.S. in February of this year with backing from the White House, the U.S. Department of Health and Human Services, and a broad coalition of public and private organizations. It is an SMS based information service that sends health tips that are timed to the mother's stage of pregnancy or the baby's age. But while text4baby was launched in a resource-rich country, we believe a similar program could significantly aid our efforts to improve reproductive and mother and child health here in Kenya. Indeed, one resource Kenya is not lacking in - mobile phones - is practically the only resource needed to implement this intervention. And more importantly, the need is arguably more severe in this region where the majority of women give birth at home and over 70% deliver without professional medical help. We will rely on community health workers (CHWs) to identify pregnant women, refer them to antenatal care (ANC), and capture their mobile phone numbers. We will then enroll all those who own a phone or share a phone with their spouse into an SMS program that will send text messages to encourage ANC attendance and help address patients' chronic lack of information on maternal health.

None of these programs are revolutionary. That's not our goal. We're just utilizing the most pervasive and most effective communication channel available in this region to promote behavior change. As detailed in MobileActive.org's white paper, Scaling Mobile Services for Development, our programs clearly fit the criteria of m-Services ready to scale. We're relying on existing technology and established infrastructure. We have a very simple and compelling value proposition. We put the needs of our users - our patients - first. Our aim isn't to get published. Our aim is to quickly pilot these programs and take them to full scale as soon as possible. But perhaps most importantly, we have a clear understanding of how to achieve sustainability. These SMS services will be free to our patients. But that doesn't mean they'll result in a net increase in our program's operating costs. Rather, if they successfully change the designated behavior they should provide a net savings. Less patients who fall out of care means less patients to follow up. More patients self-regulating their blood-pressure means less patients on hypertension drugs. And more pregnant women attending ANC means less unanticipated delivery complications and costly emergencies. Indeed, as we look toward scaling these services across our entire two million person catchment area we will assess both the health and economic outcomes of these programs. We're hopeful that it won't be long before we're able to demonstrate a clear return on investment for scaling SMS interventions for healthcare.

What's the value of a life saved?

2010-03-07T22:09:50+03:00

Many HIV/AIDS organizations brag about how many lives they've saved. PEPFAR touts the 2.4 million Africans they've put on antiretroviral therapy (ART). The Global Fund beats its chest to the tune of over 2.5 million people on AIDS treatment. But what are these lives saved really worth? It may be a question too crass for most to ask. And if you're reading this post you've probably already made the mental leap of faith that a life saved will go on to positively contribute to their family, community, and society. But where's the evidence? No, not the health economic evidence of disability adjusted life years which assumes that a healthy life-year is a productive life-year. Where's the evidence that shows how the people receiving health aid are spending their new lease on life? To put it bluntly, what's the return on our investment in the health of people living with HIV/AIDS?

Many of us working on the ground in Africa worry that we're only helping people get healthy enough to realize that they're hopeless. In much of Sub-Saharan Africa there is little opportunity for gainful employment. The unemployment rate in many countries is over 50%. And as HIV disproportionately affects people already living in poverty, treatment for HIV is far from a silver bullet for a better life. Antiretrovirals (ARVs) may restore people's immune systems, but they do little for their livelihoods. Yet people living with HIV do have valuable skills. Skills that are in high demand in the developing world. And increasingly, they are putting those skills to work.

Africa suffers from a severe shortage of trained health workers. On average, there is just one doctor for every 20,000 people in Africa (in the U.S. the ratio is one doctor for every 400 people). This dramatic shortage of trained professionals means that many Africans will go their entire lives without ever even seeing a doctor. More trained professionals are sorely needed. But Africa isn't likely to remedy this shortage anytime soon. According to WHO estimates, the current workforce in sub-Saharan Africa needs to be scaled up by as much as 140% to attain international health development targets. Of course, these countries can't wait for a new generation of trained health care workers to emerge to address a health crisis already a generation old. Nor should they. Many of their health care needs don't require highly trained personnel. It does not take a doctor to draw blood, counsel HIV patients on ARV adherence, or follow up patients who fall out of care. Many of these tasks, and others, are now being carried out by community health workers. People who, depending on the task, only need a few days or a week of training. In fact, across much of Africa, HIV care is increasingly being provided by community health workers. And many of them are living with HIV themselves.

People living with HIV are arguably the most effective advocates for HIV awareness, education, and treatment adherence. They provide a powerful testament for all of society to see that HIV is no longer a death sentence. They help combat stigma. And they help others living with HIV adhere to treatment. Here at AMPATH our outreach department is staffed entirely by people living with HIV. In fact, our outreach program was founded by our very first patient. What started as a humble operation to follow up patients who fail to attend clinic has grown to become the largest outreach program for HIV positive people in all of Sub-Saharan Africa. A staff of 70 outreach workers (all HIV positive) manage patient follow up for over 100,000 people living with HIV. Their work helps maintain the health of our patients and reduce the cost of treatment by mitigating the emergence of drug-resistant HIV. ARV non-adherence is the single largest contributor to drug resistance. And outreach workers understand this better than anyone as they themselves are taking ARVs daily. Which is why they work tirelessly to make sure that no one slips through the cracks.

Managing patient follow up is just one job that HIV positive people are undertaking. A recent study showed that HIV-positive care workers can provide a wide range of HIV services. With the assistance of a pre-programmed PDA, they can measure patient vital signs, review symptoms, and dispense patients' monthly supply of ART and medication for other infections. This model not only reduces clinic visits - saving costs for both the patient and clinic - but it can help with early diagnosis of opportunistic infections. A community based care model can also lead to improved support for psychosocial issues relating to HIV such as discrimination, abuse and food insecurity. This type of task shifting is a radical departure from traditional models of health care delivery. But it is now widely endorsed as an effective strategy to expand access to HIV care. Indeed, people receiving care for HIV are proving to be remarkably powerful allies in our efforts to end the epidemic.

So what is the value of a life saved? When it comes to HIV/AIDS, it seems that the value of one life saved is a whole lot more lives saved. All across the continent people receiving treatment for HIV are paying it forward. They are extending the help they were offered to hundreds or even thousands more. Yes, not every HIV patient winds up working to improve the health of others living with HIV. But a fair number do. Enough that I think that mental leap of faith mentioned above is based on a good amount of evidence. And as far as I can tell, our dollars for health aid are getting a much better return on investment than most of us realize.

Tragedy tourists demand refund over happy Africans.

2009-11-29T11:05:20+03:00

Western world media paints a pretty grim picture of Sub-Saharan Africans. If you have never set foot on the continent you could be forgiven for thinking that all Africans are poor, desperate and powerless. Just like someone that has never visited America could be forgiven for thinking that all Americans are fat, loud, and greedy. Of course, both are brutal stereotypes that grossly distort reality. But while America has gotten pretty good at rebranding its image in the world, Africa is still overwhelmingly typecast in the one-dimensional role of helpless victim. It's what Nigerian novelist Chimamanda Adichie calls "the danger of a single story." Which is not to say that all the horrifying stories of hunger, disease, poverty, violence, and corruption aren't true. It's just that they're not the whole truth.

Too many westerners, myself included, seek out tragedy to help fulfill our idea of an authentic African experience. We gather stories of unspeakable horrors to share alongside our photos of sun soaked safaris. The tragedies of Africa have become so ingrained in our imagination and understanding of the continent that poverty and suffering have become bona fide tourist attractions. Wide-eyed westerns are frequently spotted solemnly walking the hospital wards here in Eldoret. Slum tourism is taking off in Kibera. I understand the impulse. People want to see how "real people" live in Africa. And it certainly doesn't get any more real than a public hospital or the largest slum in Sub-Saharan Africa. But most of these tragedy tourists spend far too little time in these places to see anything more than a single story. They are, perhaps unknowingly, looking for a glimpse of Africa that mirrors that which they saw on the nightly news, on that one episode of ER, or in any number of Hollywood movies. But like both news and entertainment media, these visitors fail to shed the inherent relativity of their western perspective. All they can see is suffering and despair. But if they were to look a bit longer, if they were to look past the bias of their background, they would see that there's a humanity in Africa that the rest of the world has lost touch with.

In a survey commissioned by The Nation, Kenya's largest newspaper, a full 86 percent of Kenyans claimed to be happy. That's over 30 million happy people living in a country that is devastated by drought and famine, paralyzed by post-election violence, and struggling to come to terms with environmental degradation. That's more than 4 out of 5 people happily living in a nation with nearly 50% unemployment, 1.4 million people living with HIV/AIDS, and half its people living without access to safe drinking water. I suspect most readers of this post are familiar with at least a few of these stories of suffering in Kenya. But I doubt that many, if any, think of Kenya as a country full of happy people. Yet it most certainly is. Kenyans, it seems, don't think of themselves nearly as desperate as those in the West make them out to be.

You would be surprised by the number of Kenyans I meet that have no interest in leaving their country. I am. If life were truly as bad as the way we imagine it to be you would think everyone is desperate for a one way ticket out of Africa. But they're not. Just yesterday I met a women who wouldn't even think about trading in her humble house of mud here in Kenya for the one bedroom house her sister rents in Michigan. "My house may be made of mud, but at least it's mine," she said. My friend Dianna made her first trip to America this past August, to New York City no less. I expected her to return with stars in her eyes. But she was thoroughly unimpressed. "There's no ugali," she lamented. "And it kind of smells." Both of these women are HIV positive. Both of them came from poverty. But neither of them aspire to find a life beyond Kenya. They are happy just where they are.

This is not to say that there isn't vast room for improvement in Kenya. But rather to highlight Kenyans remarkable ability to appreciate what they have. Especially in comparison to Westerners. In fact, the Swahili word for white person - mzungu - stems from a contraction of words meaning "one who moves around." In other words, the defining characteristic of Westerners is not the color of our skin. It's our inability to stay put, appreciate what we have, and not go out in search of more. Westerners may have more worldly adventures than most Kenyans, but in many respects Kenyans lead a more enriched life.

Life is filled with hardships in Kenya. But it isn't filled with unhappiness. Indeed, Kenyans have a far greater grasp of happiness than most wazungu (plural - white people). Yet this story is seldom told. The only story we hear of Africa is that of a people that need to be saved. This single story doesn't only rob Africans of their dignity. It robs all of us of the opportunity to be saved by the humanity still thriving in Africa that the rest of the world is desperately trying to recover.

Inconvenient truths of Gates' Impatient Optimism.

2009-11-02T21:01:21+03:00

It took a couple days, but I was finally able to download the video of Bill and Melinda Gates' Why We Are Impatient Optimists presentation (well, most of it at least). I firmly support the aim of their campaign - to build a broader base of support for global health aid efforts. I also strongly believe in the strategy behind The Living Proof Project - to reframe the narrative surrounding global health from one of problems and pessimism to one of progress and optimism (full disclosure: I worked with Gates on the research and strategy behind this project). But unfortunately, I think the execution of this particular event fell a bit flat. This was meant to be Bill Gates' Al Gore moment. But the inconvenient truth of Gates' Impatient Optimism is that Bill Gates is not well suited to be the spokesperson for this movement. I don't believe the fortune he's invested has bought him the authenticity (or eloquence) needed to mobilize millions of people to get behind global health. Further, despite Bill Gates' many talents, gifted orator is not one. Don't get me wrong, The Gates Foundation has been an enormous catalyst for renewed energy and commitment to solving the health problems of the world's poor. And they've wisely poached some of the best minds in global health to help them invest their billions. But I think they would have been well advised to apply their practice of expert poaching to the position of evangelist for their advocacy campaign.

Beyond the issue of casting, the script left a bit to be desired as well. They tried to pack a lot into this presentation. Consequently, I think the story was over-simplified. They also spent too much time defending the aid model of the past half century and not enough time convincing the audience that a new era of aid accountability, effectiveness, and progress is upon us. To commit to this cause, people need to feel that things are different now. Too much of this talk implicitly suggested that business-as-usual is working, which most people don't buy. Gates talked about the impact of new investments to reducing child mortality but he didn't address the overriding issue of intervention delivery and uptake. Which, in effect, suggests we simply need to invest more money into a model that many people don't believe works. In the "answering our skeptics" segment, Gates did address the chief complaint against foreign aid - no accountability. But as Aid Watch rightfully remarked, he was unclear about how you identify the corrupt link in the chain. In my mind, this should have been the golden moment in Gates' pitch. His chance to drive home the argument that US investments in global health are directly reaching those most in need. This is the biggest point of tension in the global health debate. The stories of aid recipients scattered throughout the presentation helped demonstrate that support is reaching those in need. But quantifiable evidence was conspicuously absent.

Many will accuse this presentation of just preaching to the converted. And I agree. But I don't believe this should be taken as a criticism. This presentation is clearly one part of a larger campaign to mobilize support for global health funding. Yes, the overall aim of the effort is to persuade undecided policy makers, elected officials, and citizens to join their cause. This presentation, however, should be viewed as a first step to mobilizing a broader effort. Opinions aren't changed with one webcast. It will take time for a new global health narrative to take root. And we would be foolish to evaluate the impact of this project on a single point in time. Even Al Gore's Oscar winning Power Point did little to change people's opinion on climate change. Rather, it simply made the believers believe stronger. But Gore and his team understood the limitations of his book and film. Which is why they trained an army of advocates to give Gore's presentation. This under-acknowledged grassroots mobilization of an Inconvenient Truth is perhaps principally responsible for reframing the climate change narrative from a fringe cause of environmental activists to a mainstream movement of responsible citizens. It appears that The Living Proof Project is wisely taking a page from Gore's playbook. Melinda encouraged those watching to submit their own success stories and help share the evidence of progress underway. And I suspect my immensely talented colleagues already have a plan in place to facilitate broader participation in their project.

It is far too early to tell what effect, if any, The Living Proof Project will have. As far as internet memes go, Gates' mosquito stunt at TED spread much faster and further. But the true measure of this effort's impact should be evaluated over time by:

Tracking key attitudes and perceptions about global health and foreign aid among the aforementioned target audience (data referenced in my previous post would serve as a benchmark).
A framing analysis of media coverage of global health issues. What is the balance of content and tone of global health coverage - percentage of negative stories (problem narrative) vs. percentage of positive stories (progress narrative)?
A framing analysis of global health advocacy campaigns. What is the balance of main message and tone of advocacy campaigns - percentage of problem focused campaigns (e.g., MSF boy ad) vs. percentage of progress focused campaigns?
An online ethnographic study of issue advocacy.

I'm hopeful that The Living Proof Project will spark a new dialogue around global health. One that isn't characterized overwhelmingly by criticism and crises. Unfortunately, the news media and blogosphere have been relatively quiet on Gates speech so far (in comparison to the coverage of Dambisa Moyo's thesis, there's barely a whisper of interest for the so-called Impatient Optimist). Then again it took Al Gore over 20 years to find an audience for his cause. I hope it won't take that long to build a base of support for global health. But even if it does, as change.org rightly noted, with the world's richest couple on global health's side, we all still have reason to be optimistic.

Survey says: Americans' attitudes towards global health and foreign aid.

2009-10-09T16:01:04+03:00

In "enough with the lazy advocacy" I referred to a national study of U.S. voters' attitudes towards global health and foreign aid that I directed on behalf of The Gates Foundation. The outcome of that study went live in late September with the launching of The Living Proof Project. The aim of the campaign is to highlight the positive impact of U.S. global health investments and showcase stories of how foreign aid is empowering people to lead productive, self-sustaining lives. It's a modest effort right now, but hopefully it will gain momentum over the coming months. And hopefully it will help usher in a new era of advocacy communications that no longer rely on poverty porn and Western guilt. In the meantime, I thought I'd share some of the more interesting data points from the research that led to this project. In Harper's Index style, as follows:

...

The ranked importance of global health among 20 possible issues: 15

The ranked importance of sex and violence in the media in the same study: 12

The ranked importance of gas prices: 1

Percentage of voters who recall reading, hearing, or seeing something about global health in the past three months: 60

Percentage who described what they read, saw, or heard as negative: 67

Percentage of voters who think global health problems have gotten worse over the past 20 years: 45

Percentage who think global health problems have improved over the past 20 years: 25

Percentage of voters who think that too much aid money gets wasted because of government corruption in developing countries: 54.5

Percentage of voters who think that too much aid money gets wasted because of inefficiencies in our own government: 46.3

Number of voters who think we should not provide aid because people should learn how to help themselves: 1 in 4

Number of voters who are in favor of the US government providing food, medicine, and money to help people living in the world's poorest places: 3 in 5

Out of nine possible reasons to provide foreign aid, the ranked importance of national security: 8

The ranked importance of improving the image of the U.S. in the world: 7

The ranked importance of helping American businesses by creating new markets: 9

The ranked importance of it's the right thing to do: 1

Number of voters who are uncertain if the aid we provide is effective: 2 in 3

Number of voters who think that the aid we provide is directly reaching the people most in need: 1 in 5

Number of voters who correctly understand what the term global health refers to: 1 in 3

...

Study details: n = 2000. Fielded between June 11-23, 2008. All demos were quota filled to be nationally representative. 96.4% were registered voters: 21.9% described their political outlook as liberal, 42.8% as moderate, 30.6% as conservative. The margin of error for the total sample is +/- 2.2%.

The hazy ethics of foreign aid and intelligent television.

2009-09-26T10:50:20+03:00

Two recent podcasts from American Public Media got me thinking about how the complex ethics of foreign aid is ripe fodder for the renaissance of intelligent television. I was then reminded of David Simon's finale letter to fans of The Wire in which he writes:

"We tried to be entertaining, but in no way did we want to be mistaken for entertainment. We tried to provoke, to critique and debate and rant a bit. We wanted an argument. We think a few good arguments are needed still, that there is much more to be said and it is entirely likely that there are better ideas than the ones we offered. But nothing happens unless the shit is stirred. That, for us, was job one."

It seems to me that a few good arguments are still needed in the world of foreign aid and international development. Dambisa Moyo and her impressive/endless marketing of "Dead Aid" has definitely helped re-energize the argument. But the argument that has momentarily emerged is overwhelmingly characterized by extremes - best illustrated by the Sachs v Moyo/Easterly flare up in the Huffington Post from a few months back. Too much of the current talk around foreign aid is either for or against - more aid or no more aid. There is very little examination of the many shades of gray in the foreign aid debate. Again, David Simon:

"We are a culture without the will to seriously examine our own problems. We eschew that which is complex, contradictory or confusing. As a culture, we seek simple solutions. We enjoy being provoked and titillated, but resist the rigorous, painstaking examination of issues that might, in the end, bring us to the point of recognizing our problems, which is the essential first step to solving any of them."

I think audiences in the developed world are ready for a more nuanced examination of aid and development (so long as it's presented under the guise of entertainment). The boom in undergraduate and graduate enrollments in global health programs certainly points to a growing interest and audience. I just hope we don't spoil this moment with more skin deep awareness campaigns and one-sided storytelling. I'm sure many in this field are asking for the global health/extreme poverty equivalent of An Inconvenient Truth. Films like this could certainly help intensify interest and increase involvement among those already interested and involved. Just bear in mind that they're not likely to change public opinion overall. Nor are they likely to engage new minds and stimulate fresh thinking.

Surprisingly, serialized television may be the most effective medium to explore the complex, nuanced world of aid and development. It has the capacity to not only create issue awareness, but it can actually engage audiences to think beyond the polarizing headlines and over-simplified sound bites of most mainstream media. And it can capture and sustain the interest of an audience far broader than just those already prone to pay attention. The Wire did so in their authentic examination of the social, political, and economic life of a struggling American city. As did Battlestar Galactica as they explored religious fanaticism, global politics, terrorism, and the very question of what it means to be human. Shows like these demonstrate that entertainment media can actually help us think about the complex issues that shape our world. And they may even encourage us to engage and demand a more effective response.

I realize that using entertainment television to promote social issues and influence behavior is nothing new. But as far as I know, all previous efforts have been either purely didactic or secondary to the show's central narrative (i.e., social issue as product placement). I'm not interested in more aid propaganda or message placement. I'm interested in a thoughtful and engaging exploration of the moral, economic, political, social, religious, and cultural tension embedded within the world of international aid and development. The intersection of all these themes and the communities they represent could make for a very compelling storyline using what Stephen Johnson calls "multiple threading" - a collection of distinct narrative strands that are woven together in order to tell a more complex and comprehensive story (see Everything Bad is Good For You). And there's no shortage of archetypes to draw interesting characters from. You've got bleeding hearts, egomaniacs, eggheads, adrenaline junkies, politicians, bandits, missionaries, distant donors, neocolonialists, geeks, medics, investors and more. Some are inept. Some are corrupt. Many are smart and ambitious. Most are interested in doing good. And all save a few are first and foremost concerned with their next promotion or personal salvation. They are conflicted characters will colorful back stories. Take this vivid description from Tales From The Hood of one curmudgeonly aid worker for example:

"He was crusty, cranky, jaded, cynical, field-hardened, and prone to sweeping generalizations and ridiculously extreme pronouncements. A lifetime of aid work had taken it’s toll on his body and on his personal life. He’d been divorced a couple of times and had a couple of chronic conditions of the sort that you to tend pick up when your life is spent in or bouncing between impoverished places, always a little bit ill, sleep-deprived and far from family for weeks/months on end."

I'm doubtful that many working in aid and development advocacy would support this kind of program. On the face of it, a program that looks at all sides of the issue (good, bad, and everything in between) certainly doesn't explicitly advance their objectives. But smart marketers today know that to change attitudes and behavior audiences need to be involved in the process of meaning making. Or as Thierry Lefebvre writes in Creative Capitalism "some initial haziness - or room for improvement - can stimulate discussion and bring out ideas; haziness can be an effective marketing strategy." There is no doubt room for improvement in our collective effort to improve the health and well-being of people living in the world's poorest places. And maybe an authentic examination of foreign aid and development on the fictionalized small screen would help stimulate new ideas and build a broader base of support. But if nothing else, it would certainly make for good television.

photo credit: zinarcotics/flickr

Ths social spread of behavior.

2009-09-15T19:49:33+03:00

To follow up last week's post on the social nature of behavior change, there were another pair of great articles just published on Christakis' and Fowler's social contagion analysis of the Farmingham Heart Study data (one from Wired here, the other from the NY Times Magazine is here). Their research first hit the mainstream press a couple years ago when they reported on the social spread of obesity. The pair has gone on to explore their hypothesis further and publish their first general audience book Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives. Their research demonstrates the power of social networks to influence individual behavior. Further, it forces us to drastically recast our understanding of public health when we think of people as an interconnected network rather than a mass of autonomous individuals.

"In essence, Christakis and Fowler’s work suggests a new way to think about public health. If they’re right, public-health initiatives that merely address the affected individuals are doomed to failure. To really grapple with bad behaviors that spread, you have to simultaneously focus on individuals who are so distant they don’t even realize they’re affecting one another."

Of course, since their data is from a Boston suburb, the health issues they've examined are decidedly of the developed world. Obesity, smoking, happiness. But their hypothesis could have dramatic effects on the developing world as well. For starters, community is a much stronger condition of daily life in the developing world. In general, social ties are stronger and networks are larger in these regions. Africa may be disadvantaged in many ways, but when it comes to social capital few communities are suffering from Putnam's Bowling Alone syndrome.

"Christakis and Fowler postulate that our ability to affect people three degrees away from us may have evolutionary roots — and so may the very shape of human social networks. Tribal groups that were tightly connected were likely more able to pass along positive behaviors than those that weren’t."

The breadth and depth of social connections in the developing world could significantly support strategies aimed at behavior change. When dealing with poorly educated populations a more nuanced understanding of cultural values and social ties is critical. And if their hypothesis - that good (or bad) behaviors pass from friend to friend like contagious viruses - proves out to be true, social marketing strategists will need to rethink both their campaign plans and M&E methods. But working from a more accurate model of behavior could help campaigns addressing issues ranging from family planning to safe water to malaria prevention and more, become far more efficient and effective. And as mentioned last week, it appears that some already are. It may not be apparent on the face of it, but the use of cows to broadcast behavior change in West Pokot, Kenya does indeed have a lot in common with a Facebook application to encourage smoking-cessation in America.

"Nathan Cobb, a smoking-cessation expert and researcher at the Schroeder Institute for Tobacco Research and Policy Studies, is designing an application that Facebook users can install on their pages when they’re trying to quit smoking. The application will publicly display how long they’ve gone without cigarettes, whether they are using a nicotine patch and how much money they have saved by not smoking. The idea, Cobb says, is to take your invisible, internal battle to quit smoking and make it visible so that it can influence your friends (and friends of friends) who are still puffing away."

In other words, the cows of West Pokot and a smoking-cessation Facebook application both make an otherwise hidden behavior visible and thereby facilitate the social spread of behavior change.

Using cows to broadcast behavior change.

2009-09-08T23:03:32+03:00

I came across a story last week about a very small but successful program to curb female genital mutilation (FGM) in West Pokot, Kenya. The Kenyan government outlawed FGM nearly 10 years ago. But its deep cultural roots have allowed the tradition to endure. Given that the practice predates both Islam and Christianity it's easy to understand why, despite ample evidence of serious health risks, FGM isn't going to simply stop overnight. Changing mass behavior is seldom swift and never based on reason alone. And when the behavior in question is attached to a rich tribal, cultural, and even political tradition, lawmaking isn't likely to bring about lasting change. But when criminalization is coupled with community based interventions, sustained behavior change may actually stand a chance.

The community based intervention I came across is using cows to reward women who quit their work as female circumcisers. Six years ago, a local women's organization devised the plan when they learned that their previous efforts had failed. The program's director realized that simply talking to circumcisers about the dangers of FGM wasn't working. They found that the circumcisers often went back to the custom due to idleness. To solve for the problem they needed to do more than just ask the circumcisers to stop, they needed to get them to start something else. And preferably, that something else would replace the income the women earned as circumcisers. So they asked the women (sorry, "crowdsourced") what income-generating activity they would like to start. Aside from FGM, raising cattle is about the only way to make a living in West Pokot. The women wisely asked for cows. Those ten women are now offering to give seven heifers to other women who pledge to quit their work as female circumcisers.

This may seem like a pretty simple, common sense campaign. And it is. But I think one of the strongest features of the campaign has largely been overlooked - the role the cows play in signifying behavior change. In other words, the cows make it visible to the entire community who is no longer participating in a practice that is now often carried out in secret. And making that behavior change visible is a critical element to facilitating mass adoption.

As Mark Earls describes in HERD, most efforts to change behavior misunderstand the very nature of human behavior in the first place. They assume that human beings are rational, independent decision makers. In reality, the decisions we make are often irrational and largely influenced by others. Mark argues that to create behavior change we need to start thinking of people as herd animals. That is, we do what we do largely because of what we see others doing around us. The cows in West Pokot allow others to see what the women are, in this case, no longer doing. The cows act as both incentive to participate and marketing vehicle. The consumer analogue Earls would point to is the white ear buds for iPod. Since mp3 players are typically stashed away in the listener's pocket, the white earbuds make it clear to passersby who is actually listening to an iPod. The earbuds make the behavior visible. And making the behavior visible facilitates peoples' natural tendency towards copying. It's then no surprise that the advertising campaign that launched the iPod didn't focus on the revolutionary technology or beautiful design, it focused on that one simple way to signify iPod ownership and thereby accelerate mass adoption. In effect, the cows are the white earbuds of West Pokot's campaign to stop FGM - a way to make an otherwise hidden behavior visible. And thereby, encourage copying and mass behavior change.

This is not to diminish the role the cows play as an income generating incentive. The incentive is critical. But so is the uniformity of that incentive. Had the women not been asked to agree upon a single income generating activity and rather been given money to start a business of their own choosing, the opportunity to broadcast the behavior change would be lost. The cows act as an icon for the campaign's effort to end FGM. And in this remote corner of Kenya, the sight of women herding cattle may actually help usher in a new era of health and human rights for women.

Enough with the lazy advocacy.

2009-08-27T21:08:16+03:00

Aid Watch recently posted a satirical send-up of African advocacy videos. It may have come off as a bit too flippant for some and sarcastic for others, but that shouldn’t detract from its substance. Namely, it highlights how predictable and ineffective campaigns aimed at engaging apathetic audiences in the aid and development of Africa have become. And I’m not just piling conjecture on top of conjecture here. This perspective is based on sound research. Last year, I directed a national study, on behalf of The Gates Foundation, of US voter attitudes towards global health issues. The key findings of our study challenged the historical, and still dominant, narrative framework of global health advocacy campaigns. Much of which corroborates, albeit more dryly, the criticisms posted by Aid Watch.

The dominant narrative of global health advocacy campaigns employs a well-established script – it begins with the size and urgency of the problem, then tries to guilt the audience into caring, and concludes with possible solutions and a plea for help. During the past few decades, this narrative has helped increase awareness of several global health problems. However, it has also created crisis fatigue. In effect, this narrative has now run its course. People have heard the same story for over 20 years. At best, most audiences just tune out these campaigns today. At worst, these campaigns promote skepticism as they implicitly suggest that there is nothing to show for all the aid we’ve sent to the developing world over the past quarter century.

This goes a long way toward explaining the aid world’s current obsession with “success stories." But simply providing evidence of successes may be insufficient in capturing the attention and interest of otherwise disengaged audiences. Our analysis suggests the entire framework needs to be reconsidered. In effect, we concluded the narrative for global health needs to stop emphasizing problems and despair and start highlighting progress and optimism. The biggest challenge for most global health advocacy efforts today isn’t about recognition of the problem(s). The biggest challenge is accountability. Our research proved that the primary reason people are resistant to support foreign aid is because they do not trust that the aid provided is reaching the people it's intended for. Thus, in our estimation, effective advocacy campaigns need to start by immediately addressing the progress already underway. Americans are desperate to hear of results. And they showed a strong willingness to support further investment for proven interventions. Of course, for those organizations with no progress to report, it's probably best if you devote your resources to fixing your product before you try to market it. That trick may work with consumer products, but when it comes to issue advocacy disingenuous attempts to solicit support only make it more difficult for the efforts of legitimate initiatives to capture people's interest and involvement.

From there, our message framework recommends redefining what success means for global health in a way that mirrors the public’s definition of success – empowering people to build productive, self-sustaining lives. Receiving a bed net is not an outcome. Nor is being put on ARVs. These are just means to an end. And people rightly want to know about the end. They want to know how our aid efforts are helping create a self-sustaining society not a culture of dependency. This is much easier said than done. Now that I'm working in the field I can fully appreciate the complexity of M&E (monitoring and evaluation) beyond basic health metrics. Nonetheless, if aid organizations are serious about advocacy they should seriously invest in robust M&E programs to provide interested parties with the proof points they need to commit to their cause.

This is not to say that we can't continue to introduce audiences to the many problems of the developing world. We just shouldn't begin by dwelling on the issue. We should begin by demonstrating the progress already underway - whether that means lives saved, jobs created, or policies enacted. Just as viruses become resistant to drugs, audiences have become resistant to the standard regimen for advocacy campaigns. Audiences clearly aren't responding to these tired formulas. So enough with the lazy advocacy and wasted resources.

As for those who contend that sensationalized messages using over-simplified statistics and celebrity spokespeople are the only way to get apathetic audiences involved, I wonder how long you think you can hold their interest. Treating issue advocacy like fashion advertising will only subject your cause to the ruthless and ephemeral world of consumer trends. Here today, gone tomorrow. This style of advertising celebrates and exacerbates our disposable culture. Which may (or may not) be good for the economy, but when applied to issue advocacy it compromises the sustained interest and involvement aid groups need from their supporters to help them reach their goals. Naive supporters don't understand the consequences of their erratic involvement. Then again you shouldn't expect them to when you sell yourself like any other shiny new object.

Rethinking the "big three" of global health.

2009-08-16T22:29:44+03:00

The aim of CSIS's Mission to Kenya was to identify models of successful global health programs to help inform the Obama Administration's policy on international development (i.e., how to spend Obama's $63 billion budget for global health). Thus, my posts on CSIS's blog focused on two of the most unique features of AMPATH's model. My first post (from yesterday) focused on how AMPATH works within the existing framework of Kenya's government. My second post focuses on the interrelationship between health and socioeconomics. Again, you can read it in context by clicking here (note: they posted it as one long entry rather than the intended two separate posts). Or you can just read it right here:

When most people think of "global health" they think of disease. Specially, they think of the big three: HIV/AIDS, malaria, and tuberculosis. But the model AMPATH has developed to respond to the health crisis in Sub-Saharan Africa demonstrates a much different understanding of global health. AMPATH makes it clear that health can not be viewed as a medical condition alone. In fact, most determinants of health are socioeconomic, not medical. For example, antiretrovirals (ARVs) are largely rendered ineffective if a patient is undernourished. ARVs are free in Kenya. But food is not. So HIV+ patients can get the drugs they need to stay alive, but without food the so-called Lazarus Effect can not commence. Which is why AMPATH not only prescribes ARVs to its HIV+ positive patients, it prescribes food to patients who are undernourished. Through it's network of vegetable farms, AMPATH now provides over 40,000 patients with food per month. Of course, to simply provide medicine and food to a patient population would just create a model of dependency - a pandemic in and of itself. Enter FPI - AMPATH's robust portfolio of income security programs. These programs help ensure that AMPATH is providing a hand up to those in need, not just a hand out. Everything from microfinance to agricultural training, a handicraft workshop to a juice factory, and business consulting to a seedling nursery are designed to provide AMPATH clients the help they need to become self-reliant citizens capable of building a better life for themselves, their families, and their communities. At AMPATH, health lies at the intersection of medical care, food security, and income stability. Perhaps those of us in global health need to rethink what we mean by the "big three."