Burundi Falls Apart – Again

Bujumbura, in better days

Bujumbura, in better days

In late 2013, after a day-long bus ride through the rolling hills and lush greenery of Rwanda and northern Burundi – a trip during which one of my seatmates, evidently unaccustomed to facing her own mortality, threw up out the window – I hopped off in Bujumbura with absolutely no idea where to go next.

The Bujumbura bus park is cloistered in the back of a large, bustling market – the type of place that is wholly comfortable when familiar but bewildering and a touch intimidating when novel. My Rwandan SIM card didn’t work in Burundi and I didn’t have any Francs (or, for that matter, any French), so I wandered around until I found an exchange rate that wasn’t unreasonable and mimed a lot in order to make the exchange. SIM cards nowhere to be found and a light rain quickly turning to a downpour, I flagged a motorcycle driver, gratefully accepted his kind offer to call my friend for me, and left the park.

That bus park is likely now the site of protests against a leader, Pierre Nkurunziza, who is eschewing the constitution – if not in letter, then certainly in spirit – and running for a third term as president.

It’s now also a starting point for thousands of Burundians who are fleeing their country, to five-figure population refugee camps that didn’t exist just a few weeks ago. They’re fleeing the all-too-real chance that Bujumbura’s police force, loyal to Nkurunziza, will further turn on its citizens; that the imbonerakure, a youth paramilitary group armed with guns and nail-studded bats, will come for them and their families; that their neighbors, terrified of being thought of as “on the wrong side”, may sell them out to either group.

The prospect of a coup or a civil war has increased in the past few weeks, largely owing to military leaders who voiced support for the constitution (and therefore, the protestors).

And so Burundians are fleeing their present and their future, both inextricably tied to their recent past. A bit of history is useful here: Burundi is a landlocked country just south of Rwanda, and shares with it the bond of being previously colonized first by the Germans and then by the Belgians, as Ruanda-Urundi. The Belgians stoked (created and fomented, really) tensions between the Hutus and Tutsi, which gave way to undulating waves of ethnic violence in both countries, from their separation and independence in the early 1960s to the 1900s.

You’re certainly aware of how this played out in Rwanda: 800,000 Rwandans, mostly Tutsi, were slaughtered in 100 days over the spring and summer of 1994. The carnage subsided, and the Rwandan Patriotic Front, the rebel army that fought and beat the genocidaires, was left to rebuild the burned-out husk of a country. Over the next 20 years, spurred on by an international community flush with guilt, shame, and cash, it did just that, becoming an economic powerhouse in the region and, in the eyes of many, an exemplar for capital-G Good development in Sub-Saharan Africa.

(Obligatory caveat: Rwanda’s President Paul Kagame and his RPF deserve a great deal of criticism for the way in which they have suppressed dissent, crippled opposition, and ruled autocratically. There’s no counterfactual for how Rwanda would’ve done the past 20 years if the RPF would’ve ruled differently.)

Cibitoke, in northern Burundi. Stunningly beautiful.

Cibitoke, in northern Burundi. Stunningly beautiful.

Burundi, on the other hand, didn’t have 100 days of white-hot slaughter; it had 4,000 days of smoldering civil war. At the end of the war, with 300,000 dead, it was also left with a burned-out husk of a country, but didn’t have international guilt bankrolling its recovery; an efficient, effective autocrat forcing development at any cost; or two decades to build.

You probably knew Rwanda’s recent history; you probably didn’t know Burundi’s. The conflict in Burundi was overshadowed by Rwanda’s genocide, and, to the extent that it was news at all, the Great African Wars in the Democratic Republic of the Congo (in which Rwanda played a leading role).

Since then, of the decade Nkurunziza has been president the best thing you could say is that it could have been a lot worse. All-out war was averted and conflict stayed to a minimum.

And yet Burundi is in a really, really bad place. By whatever data source you use, Burundi is competing for the dubious honor of being the world’s poorest country; it is one of the worst places in the world for a woman to give birth; it is one of the population densest countries in Sub-Saharan Africa, with all of the land ownership issues that result; it is landlocked and has very little of value to export.

But things can get worse for the average Burundian, and quickly. In the past few weeks, the government has shut access to Facebook, WhatsApp, and other social media, and shut down the country’s main university, causing hundreds of Burundian students to seek safety at the US Embassy in Bujumbura. Demonstrators have been met with live ammunition, and the imbonerakure have harassed and murdered Burundians around the country.

This is not likely to end well, or soon. Demonstrations continue, and as the election nears, will likely be met with escalated violence. In all likelihood, things will get worse before they get better. More people will disappear or die.

Commentators have (rightly) narrowed their collective aperture to the daily demonstrations and the near-term election, but it’s worth contemplating what comes next.

In the best-case scenario, Nkurunziza wins and Burundi becomes an international pariah; aid may drop off in response, leaving the average Burundian in direr straits (indeed, this is already happening). Unfortunately, as should be obvious above, political uncertainty is just one of many challenges faced by the average Burundian; get rid of it and Burundi is still a poor, landlocked country with little of value to export and, from a tourism perspective, less to recommend it than, say, Rwanda.

In the worst-case scenario, all-out civil war, sparked by an attempted (or successful) military coup, is not inconceivable. Hundreds of thousands would flee to neighboring countries, straining the resources of those countries and aid agencies; Rwanda, worried about its stability and economic growth above all else, would intervene militarily. Economic instability, death, disease, terror, and uncertainty would follow.  What little progress was made in the past decade would vanish.

The likely outcome, of course, is somewhere in between. Nkurunziza will win, but a lot of lives will be uprooted, and lost. Burundians will be no better off than they are today. The bus park will represent desperation, hope, and hardship; one of the only ways out of an increasingly bad situation.

Book-Blogging – Americanah

For all sad words on tongue or pen, the saddest are these, ‘it might have been.’ – John Greenleaf Whittier

The air in Chimamanda Ngozi Adichie’s envy-inducing book, Americanah, is suffused through with saudade.

americanahSaudade is a Portuguese word without a direct English translation, but you probably know it: a sense of wistful nostalgia for something that probably never existed; the what-ifs and maybes that accompany a breakup.

This sense of longing – for a past since relegated to hazy, rose-tinted prologue; for a future perpetually just out of reach – crowds the oxygen from every open space in the book. Many of the characters are caught up in a near-constant fog of saudade, like the minor character Kimberly:

Ifemelu sometimes sensed, underneath the well-oiled sequences of Kimberly’s life, a flash of regret not only for things she longed for in the present but for things she had longed for in the past.

Ifemelu, one of the two main characters, begins her life in Nigeria and emigrates to America in search of a better education and a better life. She finds both, but is drawn back to Nigeria, saudade in tow:

She thanked him, and in the gray of the evening darkness, the air burdened with smells, she ached with an almost unbearable emotion that she could not name. It was nostalgic and melancholy, a beautiful sadness for the things she had missed and the things she would never know.

Ifemelu’s first love, Obinze, could not follow her to America, and ends up in London, where he also sees saudade in others:

It puzzled him that she did not mourn all the things she could have been. Was it a quality inherent in women, or did they just learn to shield their personal regrets, to suspend their lives, subsume themselves in child care?

Adichie is an enviable writer with a powerful and distinct voice; my Kindle is heavy with paragraphs highlighted both for their virtuosity and my edification. She masterfully weaves together the stories of emigrants and those who are left behind, bringing to life the bustle of Lagos and the dark gray winters of the American east coast. This is a book well worth your time.

We Know How Cerebral Malaria Kills Children — But Do We Know How to Save Them?

Donated medical devices are not the solution, part 58

Donated medical devices are not the solution, part 58 – ultrasounds in Kisoro, Uganda (photo: me, 2013)

We now know how cerebral malaria kills children. But do we know how to save them? An otherwise-fantastic NPR story suggests a solution that is, unfortunately, exactly wrong for the scope and scale of the problem: donated medical devices.

And the problem of cerebral malaria is a massive problem. Malaria is a wicked disease, causing an estimated 584,000 deaths in 2013 – 78% of which were children under five. Plasmodium falciparum, one of the five malaria species known to infect humans, is the most common and the most deadly, in part because it can end up in the microvasculature of the brain, causing what is known as cerebral malaria.

Cerebral malaria is particularly deadly for children, but until now, researchers didn’t really know why. A new study in the New England Journal of Medicine indicates that cerebral malaria kills them by, effectively, suffocating them:

Our study design addressed the sources of this uncertainty, and the findings suggest that brain swelling and the likely increase in intracranial pressure that is associated with brain swelling are strong predictors of death in Malawian children with cerebral malaria.

Basically, brain swelling kinks the brain stem, shutting off the autonomic nervous system; the patient no longer breathes independently, and, without assisted breathing through a mechanical ventilator, dies. (Now is a good time to mention that I have no clinical background, so, grain of salt…)

The NPR story highlights a potential solution:

One possibility is to try putting the child on a ventilator, John says. “Then, during a period when brain swelling might affect the child’s ability to breath, you could breath for them,” he says. Then take the child off the ventilator when the brain swelling goes down.

Many clinics in Africa don’t have ventilators or physicians trained to use them, John says. “It’s going to be very hard to implement that across Africa. But I would love to see ventilators tested.”

And if a malaria ward in Malawi can get a million-dollar MRI machine, surely somebody could donate life-saving ventilators.

Emphasis mine. This framing – donation as solution – is the absolute wrong way to think about the problem, for three reasons.

First, medical device donations fail. Predictably. All the time. I am a broken record on this subject.

Even if donated medical devices functioned as they are supposed to, this is too big a problem to solve with second-hand donations. Every mid-sized hospital that can support one (more on that in a minute) should have a ventilator, and it’s wrong to think that a second-hand donations market could support that demand.

And lastly, donated ventilators aren’t built for low-resource hospitals; they’re built for hospitals with consistent electricity, highly-trained clinical staff, and a support ecosystem with trained biomedical engineers and spare parts immediately available. None of this can be assumed for the vast majority of hospitals that would see cerebral malaria patients in low-resource regions.

The solution, then, is not a second-hand donation; it’s a ventilator designed for the environments in which it will be used in. Here I’m a broken record as well.

It is wonderful that we now know, clinically, what it takes to save the lives of children with cerebral malaria. But donated ventilators aren’t up to the task.

Book-Blogging – A Problem From Hell, by Samantha Power

A_Problem_from_Hell_(book_cover)Samantha Power’s masterful book, A Problem from Hell: America and the Age of Genocide, will make you want to do one of two things: drop everything and go work with her from the inside, to embolden our institutions and ennoble our leaders; or rage from the outside about the myriad failures of conscience and the fostering of cowardice that have consistently stymied the better angels of America’s nature.* It’s hard to see much middle ground.

In this thoroughly researched and thoughtful book, Power provides a remarkable history of modern-day genocide. She brings the reader to the death marches of Armenians in the gloaming of the Ottoman Empire to the wanton destruction of male Muslims in Bosnia and Kosovo, all the while cataloging the all-too-familiar costs of all-too-familiar inaction on the part of world leaders – saving her sharpest critiques for her adopted homeland, America. This is a book that could profoundly change the way you view the international system, and those at the top of it.

From the mid-17th century, when the Peace of Westphalia ended the Thirty Years’ War to the mid-20th century, nations were assumed sovereign over their land and their citizens (summed up best in Millennial-speak as “you do you”). Certainly, there were land wars and civil wars, insurrection and imperialism, but nations didn’t question how other nations treated their people.

And then in the early 1900s, the Ottoman Empire began massacring its minority Christian Armenian population. This is important for two reasons: it stoked the passions of an American ambassador, Henry Morgenthau, and caused him to speak out against a sovereign nation’s actions towards its people; and it inspired Raphael Lemkin to change the world.

Generally, the Great Man of History theory – the cum hoc ergo propter hoc fallacy that assumes, for example, that everything good or bad that happens during Barack Obama’s presidency is his doing – is just that: a fallacy. But Raphael Lemkin, a passionate Polish lawyer who eschewed decorum and tact in his zeal to codify genocide (his word) as a crime against humanity, was a Great Man of History. He is one of the the but fors of this story; but for Lemkin, it’s hard to see how the United Nations would ever have adopted the Genocide Convention, in December, 1948 or thereafter.**

The other but for of this story is darker and more deeply depressing: but for America’s reticence to enter the fray diplomatically or militarily, again and again, untold lives could have been saved. Power uses the taxonomy of inaction outlined by Albert Hirschman to underline the stated reasoning against action:

“Economist Albert Hirschman observed that those who do not want to act cite the futility, perversity, and jeopardy of proposed measures.”

Each category is pretty self-explanatory. Futility is the sense that nothing could help; perversity that an action could make things worse; and jeopardy a sense that American lives/interests would be harmed by action.

Power is at her best when presenting her unflinching criticism of the cowardice exemplified by America’s leaders each time they invoked the futility, perversity, and jeopardy of action. Facing genocide, or even the prospect of genocide, leaders cowed to interest groups and genocidal leaders, rather than stand up for the ideals they continually cited – nothing more or less than vague platitudes:

U.S. officials spin themselves (as well as the American public) about the nature of the violence in question and the likely impact of an American intervention. They render the bloodshed two-sided and inevitable, not genocidal. They insist that any proposed U.S. response will be futile. Indeed, it may even do more harm than good, bringing perverse consequences to the victims and jeopardizing other precious American moral or strategic interests. They brand as “emotional” those U.S. officials who urge intervention and who make moral arguments in a system that speaks principally in the cold language of interests. They avoid use of the word “genocide.” Thus, they can in good conscience favor stopping genocide in the abstract, while simultaneously opposing American involvement in the moment.

This book won the Pulitzer Prize in 2003, and for good reason; it is thoughtful, unsparing, and scathing. Reading it and thinking about it helped clarify the way I think about America’s role in the world. From the perspectives of morality and pragmatism, we have an obligation to be better; anything less than our best – the officially sanctioned torture in Abu Gharib, the deaths of innocents in misguided drone strikes, the idiocy of using a public health campaign as a front for espionage – invites bad actors to use those same methods. And inaction in the face of injustice and terror is nothing if not a green light for its continuance.

Power, now the United States Ambassador to the United Nations, has walked back some of her more forceful critiques of American action and inaction of the past, saying at her confirmation hearing that “Serving in the executive branch is very different than sounding off from an academic perch.” Activists worry that she has lost her zeal.

This strikes me as unlikely. While it is certainly true that she speaks more carefully now than she wrote before, it seems obvious that she is brilliant, passionate, and willing to do what it takes to effect the change she earnestly argues for in A Problem From Hell and elsewhere – even if that means softening her speech while sharpening her knives.

After reading this book, I’d drop what I’m doing in a heartbreak to work with her from the inside, which should be all that you need to know to go pick it up.

 

*Full disclosure: while I am temperamentally much more comfortable in the latter group – of realists and cynics, agitators and disruptors – in this case I think it’d be really dumb to do anything but side with Power.

**Lemkin is also a good reminder that Great Men of History aren’t always viewed that way during their lifetime: “Lemkin had coined the word ‘genocide.’ He had helped draft a treaty designed to outlaw it. And he had seen the law rejected by the world’s most powerful nation. Seven people attended Lemkin’s funeral.”

Friday Morning with Frank in Petionville

IMG_7798I’m just now getting to some writing I had started, but couldn’t quite finish, on a trip I took to the Dominican Republic and Haiti earlier this year…

On an beautiful, uncharacteristically quiet Friday morning in Petionville – the neighborhood in a post-Independence Day/New Year’s Day hangover – I met a guy the way a lot of travelers meet a guy (and it is usually a guy): he stops you on the street and starts a conversation.

His name was Frank, or France – he introduced himself a few times and his name flip-flopped – and he spoke “American English, not British English,” as he proudly said more than once. He wanted to know how I was doing.

If you have spent any time traveling in any part of the world, this routine is, well, routine for you. Someone is selling something – a painting, a tour, some currency – and you’re a potential buyer.

Frank, an older-but-not-elderly man in linen pants and an oversized button-down, had drawings he claimed were “special” and “unlike anything you’ve ever seen!”

His secret: “Ball. Point. Pen.”

“You’ve never seen anything like it,” he repeated, and not for the last time.[1]

I demurred, saying I wasn’t interested in them, and mentioned I was looking for some of the ironwork art that I’d heard about: old oil drums that artisans cut into sculptures and then sell to tourists, middle-class Haitians, hotels, and the like. When done poorly, they’re chintzy and the definition of knick-knack; when done well they are simple and beautiful.

Fortunately, Frank knew a guy “two blocks away” who sold sculptures like that. This struck me as… unlikely, but as I was just wandering around anyway and had nothing better to do, figured I may as well see where this would lead. It was a bright, beautiful day, the sun bearing down on the neighborhood, and adventure abounds on such days. So away we went.[2]

Ever the pesky erstwhile journalist, I pestered Frank about his life on the considerably-longer-than-two-blocks walk. He said he was 52 and, without my prompting, mentioned that the 2010 earthquake took his home in nearby Jacmel, his wife, and his three children. The earthquake came up in a lot of my conversations with Haitians, not dissimilar from how I’d talk about the cold weather with colleagues.

He said this in the seemingly-affectless, matter-of-fact way that other survivors I’ve interviewed or spoken to – whether of natural catastrophe, disease or premature death, sexual assault or war – describe near-unspeakable tragedy: as speakabale, commonplace. Normalized.

The earthquake took more than a home and a Home from Frank; it took his health and peace of mind. “I was sick from losing my family,” he said simply.

The earthquake eventually took his job, too. Frank told me that he was once a translator for NGOs and that he could still speak six languages. He ticked off a few for my benefit: English, Haitian Kreyol, Spanish, German. I believed him but must have looked more incredulous than I was, so he spent the next few minutes asking me questions in languages I recognized but mostly didn’t understand. And then he asked why Americans only speak English.

We walked down one street, then another, passing by dozens of storefronts – including a Domino’s. Every time I’d ask how much further, Frank would say “close, close” and continue on. We were perpetually “two blocks away”.

Walking over some rubble on the side of the road, I asked Frank a few questions about the cleanup and reconstruction efforts, and he angrily decried the government’s inability to make the city different; to, as Bill Clinton would say more than once, “Build Back Better.” He said that, even five years later, his country was “much worse than it should be” and that corruption was the proximate cause of this failure. I didn’t have a whole lot to go on, but anecdotally downtown Port-au-Prince was still in shambles, the ghostly hollowed-out husks of buildings still standing on many blocks, so I took his word for it.

 

“We don’t have a government,” he added, and he didn’t expect the impending dissolution of Parliament to change anything.

 

“Why do Americans like Haiti?” he asked me a few minutes later. I gave a few anodyne reasons and asked why he was curious.

 

“It’s dirty, and there’s trash all around. Why would someone want to come here?” Trying to find coming ground, I mentioned that a lot of places have trash all around – New York City, for example – but people still enjoyed visiting them.

 

Eventually, we arrived to his seller of choice, right off of the main road. The items were actually pretty nice and, after a lot of bargaining, I bought a few small things.

 

It was at this point that Frank’s words slurred together a bit more, and I realized he’d been slurring them for a while. He didn’t smell like alcohol, but the combination of slurred words and a suddenly-hostile disposition was a pretty clear indication that things had taken a turn for the worse.

 

Playing it cool, I gave him some money as a token of appreciation for bringing me to the ironworks shop; when he said “this is nothing, this is shit!” I gave him a bit more and made my way back to the part of the neighborhood I knew.

 

After that mini-encounter, Frank’s story made a bit more sense. The earthquake took his home, is family, and – likely – his sobriety. It took his peace of mind and his mental health, and there were too many physical problems for NGOs and governments to attend to already.

 

Some part of me is tempted to turn this into a Friedman-esque tale of how mental health problems, left to rot, impede economic growth and opportunity for future generations. How a small investment in counseling could have helped bring Frank and others back from the brink.

 

But this is not that story; it’s just a story about a man and the things he lost in an earthquake.

 

[1] I had seen something like it, actually – in Kigali a while back – and, to my great discredit, the fourth of fifth time he said this to me I said as much (I. Know.)

 

[2] Yes, you’re right: walking off with a stranger in an unfamiliar direction in an unfamiliar neighborhood of an unfamiliar country can be almost poetically stupid.

 

But really, most of the time it’s not: no matter where you live or travel, people are, on average, pretty great; anyone who has spent a bit of time traveling, and has been in a situation where help was needed, knows this – the young kid who steps in to translate your awful Kinyarwandan for the moto driver; the kind woman who offers you a blanket on an overnight bus from Nairobi to Uganda; the man who, for no reason other than human kindness, drives you from one city to the next, late at night in southern Malawi – and refused to accept any money for gas. If traveling has crystalized only one thing for me, it’s that people are wonderful.

 

NB: This is not to say you should be willingly naïve or unnecessarily risk-seeking – testing your luck is a great way to run out of it – merely to point out that there are times to be over-vigilant and times to be calm.

How the Bill and Melinda Gates Foundation is Re-Thinking Philanthropy

The Bill & Melinda Gates Foundation is a massive, and massively powerful, philanthropy. In 2014, it gave $3.9 billion dollars to efforts ranging from college readiness in the United States to engineering a better toilet for low-income countries. It has the ear of presidents around the world, and can change policy with its heft.

Which you probably already knew. But, rather quietly, it is also profoundly affecting the nature of philanthropy itself, by becoming an active equity investor in early-stage startups. Though it didn’t invent this model, the foundation’s sheer size and scope may convince other foundations to give it a shot, and the foundation’s public prominence draws attention to the model.

According to a recent article in The New York Times,

“The foundation has made about a dozen direct equity investments in companies over the last couple of years under the umbrella of program-related investing, as it is called in foundation circles.”

The foundation directly invests in for-profit ventures for two reasons: it believes that markets are efficient mechanisms to achieve progress; and it believes that a return on investment can be thought of not only in financial terms – the financial return on investment that most equity investors yearn for – but also in terms of social good.

Or, to put it another way: it invests in organizations that are under-valued when viewed solely through a financial lens, but are a good bet when the social return on investment (SROI) is properly accounted for.

From The Office, a co-working space in Kigali (photo: me)

From The Office, a co-working space in Kigali (photo: me)

I’ve written about this basic philanthropic model a number of times (and even have a ‘chapter’ in a short eBook about it), though previously I focused on situations where a foundation could wholly own a for-profit social enterprise – a model I termed ‘Foundation-Owned Social Enterprise,’ or FOSE.

The most salient benefit of a large equity stake in a business is that it allows a foundation to attack a problem using more traditional market mechanisms to solve market failures; as I wrote in an article at the Stanford Social Innovation Review:

Owning a social enterprise (or creating a disregarded entity) allows a foundation to efficiently effect change using market mechanisms to sell a good or service, while using philanthropic resources to address market failures and advocate a cause.

This strategy isn’t wholly positive, and sometimes it can even be self-defeating. When the Bill & Melinda Gates Foundation invests in a company, it signals to other investors two things: 1) it isn’t obvious to us that this organization can provide a market-driven financial return on investment; and 2) even if it can, we will push it to focus on low-ROI priorities, because we care more about SROI. It scares the other investors away, which could lead to a lower SROI.

And, as I’ve written previously, it can be an inefficient use of philanthropic dollars:

The FOSE model isn’t appropriate for all social enterprises or all foundations. If it’s likely that a social enterprise will be profitable, a foundation’s funds are probably better invested in higher-risk, lower-return ventures, as the social enterprise can probably raise capital in more traditional debt and equity markets.

But then again, so can issuing grants to poorly-run non-profit organizations. Many venture investments won’t pay off – but some will. The Bill & Melinda Gates Foundation seems to think that is a suitable value proposition, and hopefully its implicit advocacy for the model will push other foundations to do the same.

I’m a Published Book Author!*

About a year ago, I woke up to find that I‘d been published in the print edition of Marie Clare Australia. This was news to me, as I had not written a piece for Marie Clare Australia.

(The lesson, by the way: always read contracts)

Today, I noticed that I am now ‘published’ in an eBook*:

Screen Shot 2015-03-05 at 3.18.20 PM

Did I write the articles? Yes.

Did I know they would be used in this way? No.

Am I happy they’re now in an eBook? Yes.

Two out of three isn’t bad.

 

*Though you could argue this doesn’t really count, I’m not going to make that argument, because vanity.

C. diff is even more common than we thought. The cure? Poop.

C. difficile was responsible for almost half a million infections and was associated with approximately 29,000 deaths in 2011″

From a recent article in the New England Journal of Medicine. Clostridium difficile, or c. diff, is a truly awful hospital- and nursing home-acquired infection that is not easily cured with antibiotics; in fact, antibiotics are often the proximate cause of a c. diff exacerbation (from a previous post I wrote on the infection):

C. diff is more difficult to treat than most other bacteria; a powerful antibiotic such as ciprofloxacin (every traveler’s favorite) will wipe out much in the gut microbiome, but not c. diff. Once the other bacteria is killed off, c. diff spreads, causing inflammation of the colon, which manifests symptomatically as diarrhea, abdominal pain, and fever in mild cases, septicemia in severe. Treatment has historically involved metronidazole or a vancomycin/rifaximin combo, which (typically) does works on c. diff.

But those antibiotic courses are long – up to a month – and only work initially 60% of the time; less often for a second or third bout of c. diff. Sometimes, a patient will have to be in a hospital bed to receive the treatment (in an isolation bed, which are always in high demand).

The solution? Poop. I’ve written enough about fecal transplants that it isn’t worth re-hashing here, but suffice it to say that the procedure is remarkably effective at tamping down a c. diff  exacerbation.

Nearly 30,000 Americans are killed annually by c. diff, which is nearly as many as are killed by motor vehicle accidents. They don’t have to be; fecal transplants are a cheap, and effective treatment, with few side effects to boot. Cue all the frustration.

The Underpants Gnomes Fallacy and Design

Details are the worst.

We’re enamored by The Big Idea but bored by The How. We love the well-designed device but loath the discussion of a distribution strategy. We rave about the Sexy Silver Bullet that will solve [enter your pet social concern here] but gloss over the plan to do so.

As Adrianna McIntyre, wunderkind health policy wonk and writer, put it to me recently on Twitter, “Implementation just isn’t good fodder for the thinkpieces.”

 

 

She’s absolutely right. It isn’t. The details are, to put it mildly, unnervingly boring for all but the most wonky of us. The pessimistic take is that journalists write what will be read, and there isn’t demand (or, if it’s in print, space) for the messy discussion of how it will actually work. Implementation, therefore, necessarily takes a backseat to the quick description of a “live-saving” or “world-changing” technology, and society is worse off for it.

Adrianna was referring to policy, but the sentiment rings true for other sectors, too – particularly, I’d argue, the large umbrella of “technology for development.”

Take this recent article about D-Rev’s redesigned phototherapy unit, BrilliancePro; it’s an exemplar of this type of article. The general formula is simple: focus on a social problem through the lens of a technology-reliant solution; make a bold claim about the solution’s impact on the world; qualify the claim with a “to be sure” paragraph; end on an optimistic note.

BrilliancePro is used to treat neonatal jaundice, an extremely common condition – according to UCSF Children’s Hospital, 50-60% of newborns are jaundiced in the first week of life – with an extremely simple treatment: shining blue light on jaundiced babies for a few days.  Brilliance and BrilliancePro exist because traditional phototherapy units aren’t designed for low-resource environments, a topic about which I’ve written previously and won’t revisit here; suffice it to say that widgets should be designed for the environments in which they’ll be used in.

And Brilliance Pro is well designed for the environment it will be used in. The article highlights all of the improvements and innovations that make BrilliancePro a great product, of which there are many: it’s sleek and includes a light meter, for example, which low-resource hospitals value but typically can’t afford.

But buried at the end of the article is this: “Getting Brilliance into hospitals is a challenge unto itself, and D-Rev’s success in that regard has been more measured.”

Frustratingly, the article gives a situation and hints at the conflict, but fails to provide any resolution; the ‘so what’ is left out.

This article was put up on Wired’s Design vertical, so you could argue that the business side of the business was purposefully – even appropriately – neglected. But this seems odd; an award-winning product without an end user is just a failed, award-winning product. The design of a business is just as important as the design of a product, and a product that wins plaudits for its design without actually getting to the end user is just as much a failure as one that doesn’t win awards and fails. Design is about more than design.

This shouldn’t be read in any way as a criticism of D-Rev. I wholeheartedly support its process and its products, and think it is probably the best at what it does. I’ve met Krista Donaldson, the organization’s CEO, and other members of its team in the past, and found all of them to be smart, pragmatic, and passionate. Above all, the team is incredibly thoughtful about how it designs products – “user-obsessed” isn’t just marketing spin – and it spends nearly as much time working on how to get its well-designed products to these users (who really like the product, based on my interactions with a few of them).

And anyway, D-Rev has actually been pretty successful. According to the Health Impact Dashboard D-Rev has on its website, it currently has 779 Brilliance units in nine countries*, and a lot of lives have been affected.

D-Rev1

From D-Rev’s Health Impact Dashboard

 

But it’s fair to say that D-Rev has set its sights a lot higher than this. The Wired article can’t answer the questions it never asks: How does D-Rev plan to get these brilliantly-designed products into hospitals? Why hasn’t it seen the type of success it should expect?

Yes, these are difficult questions to answer; it’s simpler to state that the “payoff from the incremental changes could end up being far more profound” than to investigate whether that is actually likely to happen. By not asking or answering these difficult questions, the journalist commits the Underpants Gnomes Fallacy:

Step One: Design a Cool-Sounding Product. Step Two: ? Step Three: Change the World!

Phase One: Design a Cool-Sounding Product.
Phase Two: ?
Phase Three: Change the World!

I’d argue that D-Rev’s to-market issues have less to do with its design or business model than with a variety of exogenous factors it can’t control (and will do so in an upcoming piece). This only underscores the point: in low-resource markets, distribution is hard. Even a smart organization like D-Rev still has trouble getting its product into the hands of end users.

In other cases, though, an appropriately skeptical look at an overhyped design could have actually made a difference.

Here the PlayPump is instructive**. Invented in 1989, the device – which uses a merry-go-round to pump water into a tank, which can then be drawn from a nearby spigot – came to international acclaim in the early 2000s, winning an award from the World Bank and $16.4 million from USAID, PEPFAR, and the Case Foundation.

The PlayPump's design seems great, but the hype about it far outpaced its impact

The PlayPump’s design seems great at first glance (if you squint and don’t think about it too much), but the hype about it far outpaced its impact

Amy Costello, then a PBS Frontline reporter, produced a positively glowing feature on PlayPump in 2005. But she went back to Mozambique in 2009 and found PlayPumps broken and unused, their promise unfulfilled. Costello then filed a much more critical report, and PlayPump’s grand schemes and overblown rhetoric never came to fruition.

To its credit, one of PlayPump International’s backers, the Case Foundation, admitted that it made mistakes in rolling out the device and committed to changing course. This is a great, laudable, and difficult thing to do. But I suspect that a bit of well-placed skepticism at the outset would have led all involved in this directly much earlier.

Skepticism is good for designers and potential designers, too. It forces them to question their assumptions and to think deeply about more than just the physical design of a product. It forces them to up their games.

To a person, journalists are hungry to tell difficult, engaging stories. But, especially when it comes to design, telling the whole story requires a deeper examination of how the design will lead to the impact they claim it will. Readers deserve it.

 

*The Wired article had much different figures – 1,100 units in 23 countries. Not sure where the discrepancy comes from, but here I’m using D-Rev’s figures.

**There are plenty of others – the Soccket immediately comes to mind – but the PlayPump is more or less the platonic ideal of an over-hyped design that little-to-no skepticism