John Green Goes to Ethiopia

John Green recently went to Ethiopia with the Bill & Melinda Gates Foundation (and possibly with Save the Children too?). He just posted his first video about the experience, in which he visits Yekatit 12 Hospital (a hospital I visited earlier this year) in Addis Ababa, Ethiopia’s capital: It’s worth quickly shading in a few things:

  • The “jerry-rigged” CPAPs – basically devices that, in this context, keep babies’ airways open – require a source of oxygen to function; Yekatit 12 buys large oxygen canisters from a local supplier in Addis Ababa. Unfortunately, that local supplier is currently the only supplier of canister oxygen for the entire country. I visited the production site – which was recently privatized after years of being owned and operated by the government – and found it to be run by a nice, bright, passionate team. But oxygen compressors are difficult to maintain and, at some point the compressor will break down. When it does, hospitals like Yekatit 12 will be without their only source of oxygen canisters; hospitals hours away from Addis Ababa will be in an even worse position. Compressed oxygen is an absolutely critical medical supply; it’s needed for, among other things, anesthesia machines (shameless promotion: well, most of them, anyway). Without it, patients suffer. This is an extremely under-discussed problem with too few decent solutions for East Africans
  • Green highlights Kangaroo Mother Care, which is fantastic – it’s really, really great. The incubators in Yekatit 12? Not so much. They look old, were almost certainly donated secondhand, and require a constant source of electricity. While in Uganda, I wrote about an alternative: the Embrace BabyWrap, a bright blue bag with a warming pack that keeps a baby warm for hours
  • According to Green, there are seven neonatologists in Ethiopia, a country of something like 94 million people. Keep in mind, all seven neonatologists almost certainly live in one of the large population centers – probably Addis Ababa, maybe Bahir Dar or Jimmy or Hawassa – meaning that the neonatologist-to-nurse ratio is much lower in the rest of the enormous country
  • I need to mention the troubling political situation in Ethiopia, a country that imprisons journalists and bloggers on account of “destabilizing” the country
  • Finally, it’s worth being at least a little skeptical about Ethiopia’s child mortality statistics, for many reasons, two of which I’ll quickly touch on. First, these figures are really hard to collect, and they are, by their very nature, speculative and gameable. Just as importantly, check out the date his graph starts: 1994, just after the Derg (led by Mengistu Haile Mariam), a junta that put almost no effort into building the country’s health infrastructure, were ousted by a rebel group. Therefore, the mortality statistics are almost certainly “artificially” high compared to peer countries: a relatively small investment is likely to yield a relatively high ROI. This isn’t to say that Green is wrong when he says that the Ethiopian government has put a lot of effort into improving its health system; when I met with leaders of the MoH, hospital administrators, and regional health directors, it was obvious each had a passion for the job, and the country has extremely ambitious plans and goals. As always, it’s worth viewing data with a skeptic’s eye

7 Must-Read New Yorker Articles on Global Health

I made this short list for Gradian’s blog and figured it was worth reposting here. Seriously: read these articles.

___

The New Yorker opened its archives this week as part of a website redesign. If you’re a regular reader – or, let’s be honest, like most of us you just try to keep up with it – you know how fantastic its articles are.

If you’re not a subscriber, we’ve got you covered. Here are a few of our favorite global health/surgery/anesthesia pieces; check them out and let us know yours!

M0000173 First demonstration of surgical anaesthesia, 16th Oct 1846.

The first demonstration of surgical anesthesia, in 1846 (via)

Slow Ideas, by Atul Gawande (July 2013) - “Why do some innovations spread so swiftly and others so slowly? Consider the very different trajectories of surgical anesthesia and antiseptics, both of which were discovered in the nineteenth century”

HIV

HIV virus particle (via)

 

The Doomsday Strain, by Michael Specter (December 2010) - can scientists and researchers catch the next spillover disease before it spread? (I also wrote about Oxitec here)

A (non-genetically-modified) mosquito (via)

A (non-genetically-modified) mosquito (via)

 

The Mosquito Solution, by Michael Specter (July 2012) - can we eradicate a deadly disease by genetically modifying mosquitoes? Should we?

In 1944, a U.S. Army serviceman sprays an Italian woman with DDT (via)

In 1944, a U.S. Army serviceman sprays an Italian woman with DDT (via)

The Mosquito Killer, by Malcolm Gladwell (July 2001) - DDT was an integral component of the American effort to eradicate malaria in the states. The story of Fred Soper, the inventor of DDT

Turkeys - a vector for avian flu (via)

Turkeys – a vector for avian flu (via)

Nature’s Bioterrorist, by Michael Specter (February 2005) - on avian flu

 

A poster warning of Tuberculosis and influenza (via)

A poster warning of Tuberculosis and influenza (via)

A Deadly Misdiagnosis, by Michael Specter (November 2010) - tuberculosis is a really, really hard disease to kill. Why?

A vial of smallpox vaccine (via)

A vial of smallpox vaccine (via)

The Demon in the Freezer, by Richard Preston (July 1999) - the story behind the eradication of smallpox

Sunday Links

Thursday Links

Sunday Links

A few thoughts and associated links on the Great Disruption Debate of 2014, triggered by Jill Lepore’s scathing indictment of the theory of disruptive innovation in this week’s New Yorker:

  • The theory of “Disruptive Innovation” is a very narrow one, and pretty easy to understand: upstart companies produce cheaper, less-”featured” products that reach customers who otherwise could not afford the more expensive product or don’t need all of the features. Over time, the upstarts produce slightly better, slightly more expensive products, which eventually begin to compete with the incumbents’ products, and often overtake them – eventually. Hewing closely to this definition, AirBnB is a disruptive innovation (using technology to offer a theoretically cheaper, inferior product to a hotel room), but Uber is not (Uber is a better, more expensive offering to traditional taxis – though you could argue that Uber is actually disrupting the personal car)
  • Most individuals and companies opining about the need to “disrupt” this or that aren’t referring to the theory; the term has been watered down and broadened to include basically any type of innovation. The article both outlines this trend and exemplifies it; Lepore, for example, counts the financial innovations that helped stoke the financial crisis in 2008 (e.g., collateralized debt obligations, mortgage-backed securities) as “disruptive innovations,” but it seems fairer to count them only as “innovations.” Not all innovations are disruptive innovations, and not all “disruption” is disruptive innovation (Uber is certainly disruptive in the colloquial sense of the word)
  • Apropos of the point above: Taco Bell doesn’t really need a “resident disruptor” because it already churns out the cheapest, shittiest tacos available. In Christensen’s parlance, the Doritos Locos taco is a sustaining innovation (Taco Bell is making what is theoretically a “better” taco), not a disruptive one
  • The article misses the point when it comes to “disrupting” people-centric industries like education, health care, and journalism, arguing that these are not disrupt-able because they have non-financial “obligations” and are, therefore, not “industries.” This is simply uninformed. For example, Massively Open Online Courses, or MOOCs, are routinely derided for being a poor alternative to on-campus learning – and that’s the point. MOOCs are, so far, a cheaper, inferior substitute for on-campus learning – but they meet the needs of some people. Over time, they’ll get better and more expensive, and more people will use them. They are, definitionally, a disruptive innovation
  • Lepore weakens her argument by including a strange you-damn-kids-get-off-my-lawn paragraph about kids and their scooters and their jeans and their coffee machines – preferring, presumably, the cold professionalism of a sclerotic newsroom to a more comfortable working environment
  • Regardless of the virtues or vices of Lepore’s article, this interview with Clayton Christensen (author of The Innovator’s Dilemma and the man who has done the most for – and gained the most from – the theory) is really, really strange. Christensen, a professor at Harvard, is generally regarded as a pretty nice guy, but the interview is rambling, angry, and sees Christensen use the third person instead of the first
  • It was simply irresponsible journalism for Lepore to not interview Christensen for the article, as Christensen claims
  • Will Oremus wrote a very entertaining mini-rebuttal to Lepore’s article: “Lepore’s main point is that disruptive innovation isn’t all it’s cracked up to be. At least, that seemed to be her point up until the point where she started talking about journalism”

Book-Blogging: The Great Escape, by Angus Deaton

TGE

The past two hundred years have borne awesome changes to the world (in the definitional sense of the word): world population has septupled – septupled! – and, looking at the way lives are lived now, anyone living in 1814 would likely conclude (not wholly incorrectly) that we are Sorcerers Practicing Black Magick. Technologically, socially, and economically, the past 200 years have been vastly different than the preceding 200. Or 1,000, for that matter.

How did a few nations break thousands of years of (relative) constancy and become significantly wealthier and healthier than ever before? Why didn’t, and haven’t, others? What’s happening now, and what can we expect to happen in the future?

Angus Deaton, a professor at Princeton University, wrote a masterclass of a book, The Great Escape, dissecting these questions. I can’t recommend it highly enough to anyone interested in health and wealth; medicine and economics; the past and the future.

The book isn’t actually a book; it’s more like a book and a chapter-length op-ed, and it’s worth reviewing each separately. The book, Chapters 1-6, is the most complete accounting of the recent changes in health and wealth in the world that I’ve read. The op-ed makes the case that foreign aid weakens recipient governments – especially in Sub-Saharan Africa, where in many countries it approaches three-quarters of government expenditures – and as a result harms the people it putatively tries to help (though “tries to help” does a lot of work in that sentence, and Deaton argues it often isn’t about helping them but us).

The first few chapters walk through the truly shocking increases in health many wealthy societies have witnessed during the past few generations. This “aging of death,” as Deaton delightfully calls it, started around the 1850s in Western countries and eventually filtered down to less-developed regions in the 1950s and thereafter; it continues to this day.

As Deaton points out, life expectancy is a confusing metric, and kind of a bad one at that. Take the fictional country of Macronesia: because of a genetic defect, half of its population dies at birth, and half lives to be 100 years old. It’s average life expectancy is, therefore, 50 years – but no one lives to be just 50, and those that make it past their first day have 100 years of life left. 50 is, in this context, a meaningless number. But it’s Macronesia’s life expectancy just the same.

And so it is with many real countries that have intolerably and unconsciously high infant and child mortality rates. Think America at the turn of the 19th century, when life expectancy was something like 40 (a generous, speculative figure that is almost certainly on the high side). But that’s because so many kids died. To pull a few (admittedly non-random) examples of lifespans we would consider long today, George Washington wasn’t 40 when he died; he was 67. Benjamin Franklin, John Adams, and Thomas Jefferson were 84, 83, and 90, respectively.

(Because I just have to: in one of history’s great coincidences, Adams and Jefferson – one-time sworn political enemies who nevertheless developed a long, deep correspondence by pen in the gloaming of their post-presidential lives – died on the same day in 1826 – the Fourth of July. The 50th anniversary of the official signing of the Declaration of Independence. Because of course.)

Another problem with life expectancy: as an American white male, my life expectancy at birth in 1987 was 72.1 years – but that was an outdated figure almost as soon as the ink dried on that year’s actuarial table. Changes in medicine, technology, and policy over my lifetime will almost certainly mean that my (American, white, male) peers and I will live, on average, far longer – even past 100.

Though he (rightfully) questions the use of life expectancy as a metric in and of itself, the massive uptick in it is because far, far fewer children are dying than before, and that this is because of public health measures:

The major credit for the decrease in child mortality and the resultant increase in life expectancy must go to the control of disease through public health measures.

Because of public health measures, when we talk about countries, we no longer talk about neonatal and child deaths per 1,000 live births; we talk about them in numbers greater than that by two orders of magnitude: 100,000.

As a result, in America, life expectancy increased from 47.3 in 1900 to 77.9 in 2006. He puts it more colorfully than I could:

One way in which the transition is sometimes summarized is to say that diseases move out of the bowels and chests of infants into the arteries of the elderly.

The second half of the book describes the unprecedented economic growth that began in the 1800s and continues today. I won’t get into it much (if there’s any story here you already know, it’s this one), and only will make a few points about measurement.

Deaton convincingly argues that defining and measuring poverty across countries is much more difficult than most casual observers realize. A dollar goes further in India than in the states, and even the calculation to account for this – the wonkily-named “Purchasing Power Parity” – is flawed in obvious and predictable ways. Defining poverty is also difficult in America itself; the poverty line was first chosen then rationalized, and has always been politically fraught.

Gross Domestic Product, or GDP, is a problematic measure, too (and a recent one, as Planet Money helpfully discussed on a recent podcast episode). As Robert F. Kennedy pointed out, it measures much of what we don’t necessarily want, and little of the important, ephemeral things in life.

(Deaton doesn’t even dive into the difficulties about figuring out the GDP of a country – especially a poor country – a monster of a problem in itself).

At times during the book part of the book, Deaton is a bit of a broken record – mentioning too many times to count that “escapes leave people behind, and luck favors some and not others”– but this is a minor sin easily overlooked.

The op-ed at the end is, to put it mildly, polarizing. Deaton is an intellectual monster in the field of development economics, so his firmly planting a foot in the “anti” camp made waves. I won’t get into the arguments much – there’s simply too much to cover – but will give a short summary and a note of admiration.

USAID Food Bag

His argument basically rests on the idea that foreign aid – even the 100% benign, apolitical aid, if it exists (though there’s reason to believe it doesn’t) – necessarily distorts the policies and actions of recipient governments. Governments that are strong don’t need the aid, he argues, while governments that aren’t strong (read: corrupt, authoritarian, or both) will be hurt by the aid. In other words, think of it like the Halstedian “radical mastectomy” of aid: it’s used when it either can’t help anyway or isn’t needed in the first place, and causes severe trauma either way.

(For more on radical mastectomies and cancer, read The Emperor of All Maladies, a wonderful book that I reviewed here).

Deaton does mildly argue that aid directed towards the provision of certain types of health care (safe water, sanitation, pest control) can be, on net, a capital-G Good thing. And he voices approval for certain types of indirect aid: funding research into Neglected Tropical Diseases; advocacy for policy changes that promote migration and trade; removing harmful rent-seeking subsidies; et cetera But overall, he’s quite skeptical of direct-to-consumer aid.

Deaton’s op-ed chapter is admirable for its bluntness and for its acceptance of a hard truth: getting rid of aid may be normatively the best for the long-term fate of low-income countries, but in the short-term this is both impossible – does anyone really think USAID and the World Bank are just going to disappear? – and has serious immediate consequences (people will die). But he argues for it anyway, and kudos to him for having the bravery to do so.

This book – and its accompanying op-ed – is fantastic. Full stop. Buy it now.

How a Blended Model Can Solve Some Market Failures (Part 2) – at NextBillion

Originally posted at NextBillionsee here for Part 1

Training on the Universal Anaesthesia Machine at Connaught Hospital in Freetown, Sierra Leone (photo: Steve Rudy)

Training on the Universal Anaesthesia Machine at Connaught Hospital in Freetown, Sierra Leone (photo: Steve Rudy)

A bit of background is necessary to help illustrate how we use this foundation-owned social enterprise model. In the 1990s, a British anesthesiologist working in Malawi, Dr. Paul Fenton, created the Universal Anaesthesia Machine (UAM) in what was a textbook case of necessity birthing invention: When the electricity cut out or the supply chain failed to provide oxygen canisters on time, the conventional anesthesia machines he used to provide anesthesia wouldn’t work. Without the ability to provide general anesthesia, some surgeries couldn’t be performed and patient care suffered.

The machines Fenton had on hand weren’t designed to function in such an environment. So he built his own anesthesia machine that would function without electricity or compressed oxygen, and the forerunner to the UAM was born.

Later, Fenton partnered with a foundation to refine his design. Market research and clinical feedback confirmed what he and his colleagues intuited: There was and still is an enormous need for a device like the UAM in many low-income countries and resource-constrained hospitals around the world.

With a compelling product on its hands, the foundation had to decide how to get it to hospitals around the world. For a variety of legal and technical reasons (an entire future blog in itself), the foundation chose to begin by spinning off the idea into a separate legal entity, and Gradian Health Systems was created, with the foundation as its sole owner and investor.

Like any organization, we have a limited budget and we use it to maximize the return on investment. But the foundation judges its success based not on how much profit can be generated but on the “extra-financial value” created – known in philanthropic circles as the “social return on investment” (SROI). The more people that have access to safe surgery and anesthesia through the use of the UAM, the higher the SROI.

Early on, we decided that donating UAMs was an inefficient way to produce this SROI; our impact was constrained by the number of machines we could donate based on a yearly budget. Demand exceeded supply.

So we chose to use a model that allows us to scale according to demand: selling machines at their marginal manufacturing and shipping cost. This frees up our philanthropic funding to build out a potential market for the machine and address the post-sale market failures described above.

Like a traditional business, we’re investing in the creation of the market by spending money up front – on marketing, research and development, international quality certification and the like – to drive future sales of the machine. Unlike a traditional business, we don’t expect to recoup that cost; it’s paid for with philanthropic funding so that we can offer the machine at as low a cost as possible – an important factor in hospitals’ buying decisions.

Crucially, the foundation’s investment allows us to address the market’s failure to address the post-sale needs of the customer: robust machine training for clinicians and biomedical technicians; easily accessible, open-source spare parts that can often be procured locally; timely maintenance and repair backed by warranty. Using philanthropic dollars ensures that these critically important components will be high quality and ubiquitous, even if they aren’t profitable.

To be sure, these components are expensive, but they are vital to ensuring the provision of safe surgery and anesthesia and, to our customers, produce the highest and longest-lasting SROI.

The idea of a foundation owning a commercial entity seems to be a novel subset of venture philanthropy that offers any number of exit options: the social enterprise could spin off as a for-profit, a nonprofit, or could stay a long-term investee of the foundation. Ultimately, this decision simply depends on the aims of each organization and the needs of the customer.

Whatever the decision, it’s critical that the foundation and social enterprise commit to one another; it would challenge the sustainability of philanthropic investment to, say, have the foundation simply stop funding at the wrong time.

And this model isn’t right for every situation. Foundations should not waste fixed philanthropic dollars on markets that aren’t failing, and some philanthropic solutions simply can’t rely on a market to offer goods and services. But it can be an effective solution when, as in our case, a market exists but is largely failing to serve the customer.

Foundation-owned social enterprise is a novel philanthropic model that has the potential to help solve market failures in a variety of contexts. It’s so novel, actually, that we don’t know of many other instances of its use; if you know of an organization doing something similar, let us know.

 

How a Blended Model Can Solve Some Market Failures (Part 1) – at NextBillion

Via NextBillion:

 

An operating theater at Connaught Hospital in Freetown, Sierra Leone (photo: Steve Rudy)

An operating theater at Connaught Hospital in Freetown, Sierra Leone, using the Universal Anaesthesia Machine (photo: Steve Rudy)

My organization, Gradian Health Systems, uses an atypical business model to get our product into the hands of those who could benefit from it.

We produce a unique medical device, the Universal Anaesthesia Machine (UAM), which is designed to provide anesthesia in any environment ­– including infrastructure-poor hospitals that lack consistent access to electricity or compressed oxygen (necessary to run typical anesthesia machines).

The model we use to manufacture, sell, distribute and support the UAM, foundation-owned social enterprise – more technically, a limited liability corporation wholly owned by a 501(c)3 private foundation –  is a novel means to combine the best features of philanthropy with the best features of business. It allows us to serve as a commercial entity using market mechanisms to sell a product, and as a nonprofit using philanthropic dollars to address significant market failures.

To understand why we use this model, you really need to understand the challenges that low-income country markets create for medical equipment manufacturers and why conventional models haven’t worked.

In high-income countries, medical device manufacturers have developed an effective and lucrative business model predicated on accessing multiple revenue streams. As you’d expect, the initial sale is one such stream, but lesser-known complements are the sale of a high-margin, long-term service contract and the recurring purchases of (often proprietary) spare parts and consumables.

And the model works. In these markets, strong infrastructure and a robust supply chain ensure comparatively low prices for proprietary spare parts and consumables – all of which hospitals can afford. Just as critically, facilities and regions have a deep supply of highly trained biomedical engineers to fix the often quite intricate and sophisticated devices.

In low-income countries, though, a dearth of hard and soft infrastructure strains this model to its breaking point. To take just one concern, it can be very difficult to find biomedical engineers trained to maintain and repair intricate and sophisticated devices; there are nine in Malawi, for example. Bringing in outside expertise is a time-consuming and expensive process, leading to long inoperability periods and high costs for already cash-strapped hospitals.

And all of this assumes that the product is right for the environment, which, as I’ve discussed before, simply isn’t the case for low-resource environments. Even if a hospital can pay for spare parts, consumables and repair, a machine that requires compressed oxygen still won’t consistently function in a hospital that often runs out of it.

Organizations not seeking to profit when trying to fill this gap have thus far generally failed to do so in a cost-effective and sustainable way. The most common model we’ve seen to address this low capacity to pay is to donate used, second-hand equipment (which I’ve written about previously for The Atlantic).

This donation model is problematic for two reasons. First, like the new, for-sale equipment described above, most used, donated equipment simply isn’t designed to function in infrastructure-poor environments. And second, sometimes donated equipment is positively ancient and simply should not have been donated in the first place; an old, out-of-production machine likely won’t have spare parts or consumables in production, making them more difficult to source.

The end result of these models is a staggering percentage of inoperable medical equipment in low-resource environments. Estimates vary, but 40 percent to 80 percent of medical equipment in sub-Saharan Africa is considered non-functional.

This makes us believe that there is a significant market failure in the manufacture and sale of medical devices in low-resource countries; improper devices are being sold or donated and are largely failing to serve the communities in which they’re placed.

We think it’s time for a new solution.

Foundation-owned social enterprise remixes conventional for-profit and nonprofit models to create something new.Combinatorial creativity at its finest, the model draws on the best of both business and philanthropy to sustainably address old problems.