Category: Global Health

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.

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.

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.


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

The “Misuse” of Bednets Shows the Need for More Community-Led Development

What’s worse: malaria, or hunger?

If you’re reading this, there’s a pretty good chance that you’ve never had to Would You Rather that question.

Millions of people, though, have to weigh the relative chance of their children getting malaria vs. not having enough to eat. Every day. As Jeffrey Gettleman writes in a long piece for The New York Times, many choose the former:

But Mr. Ndefi and countless others are not using their mosquito nets as global health experts have intended.

Nobody in his hut, including his seven children, sleeps under a net at night. Instead, Mr. Ndefi has taken his family’s supply of anti-malaria nets and sewn them together into a gigantic sieve that he uses to drag the bottom of the swamp ponds, sweeping up all sorts of life: baby catfish,banded tilapia, tiny mouthbrooders, orange fish eggs, water bugs and the occasional green frog.

And later:

For Mr. Ndefi, it is a simple, if painful, matter of choice. He knows all too well the dangers of malaria. His own toddler son, Junior, died of the disease four years ago. Junior used to always be there, standing outside his hut, when Mr. Ndefi came home from fishing.

Mr. Ndefi hopes his family can survive future bouts of the disease. But he knows his loved ones will not last long without food.

Emphasis mine. For those who haven’t used one before, this is what a long-lasting insecticide-treated bednet (LLIN) looks like (though they aren’t always pink):

A bednet at the Dive Inn, in Kampala

A bednet at the Dive Inn, in the Kabalagala neighborhood of Kampala, Uganda. Yes, the Dive Inn; worth every penny of the 10,000 UGX ($4) per night cost. (Credit: Mike Miesen)

When used correctly – as they almost always are – LLINs are an incredibly cheap and effective way to prevent malaria and the child deaths, anemia, and other issues it causes. That understates it; they are the best means of preventing malaria. Full stop*. GiveWell helpfully reports on the evidence supporting LLIN distribution here, and it has listed the Against Malaria Foundation (AMF) as one of best uses of charitable funds for the past few years.

But as Gettleman notes, sometimes people use LLINs in other ways, ranging from the sartorial (as a dress or veil) to the life-saving – just not in the way the global health experts assumed they would.

Because it turns out that LLINs are, well nets – and really cheap ones at that. They have incredibly small holes, meaning they’re great at catching small fish like these, from Lake Malawi:

fish like this

Fish drying on the shore of Lake Malawi. Fun fact: with some salt, they’re pretty good. (Credit: Mike Miesen)

For communities living on the shores of large lakes and small streams in east Africa, fish are one of the most reliable sources of calories – and, crucially, protein. They provide live-saving calories to children and adults.

And yet there are people that are shocked – shocked – that some choose to use the nets that “we” gave them to prevent malaria for fishing; that the nets are being “misused” or that “our” benevolence is spurned by ungrateful recipients.

This is misguided. Using LLINs for catching food rather than preventing malaria is an entirely rational decision; it’s so rational that nobody should be the least bit surprised.

The problem isn’t “misuse.” It’s poverty, an utter lack of opportunity. When there’s no work to be done, individuals and families – even entire communities – make do the best they can. They may sell the excess vegetables that come from their plot of land so they can afford school fees, or they may “hack” the LLINs given to them to prevent malaria into a net used to catch fish.

At a broader level, “misuse” is really just another way of saying that NGOs and multilateral organizations failed to do what they were established to do. They impose their answers onto communities, rather than simply ask those communities what they actually need.

This is why integrated, community-led development provides a better path to real and sustainable development. It refuses to tell communities what they need or to implement solutions that aren’t agreed on by the community. Community-led development looks different than top-down development, and so it scares a lot of development experts, many of whom think that communities need solutions brought to them.

So, what does it actually look like? Often, like this:


A community in Nyagisenyi, Rwanda. (Credit: Mike Miesen)

This is a community in Nyagisenyi, Rwanda, a chilly village near the edge of the country’s border with the Democratic Republic of the Congo and Uganda. The community is building a vocational school that will teach its children and young adults the skills to be seamstresses, carpenters, and more. The project is led, planned, and executed by the community, with support and facilitation from Spark MicroGrants, an NGO that provides small grants — just $3,000 – $10,000 — to entire communities. Spark MicroGrants places virtually no restrictions on the funds, provided that the community (women included) comes to consensus on a project.

Community-led development also looks like this:


How one woman used the approximately $1,000 given to her by GiveDirectly. (Credit: Mike Miesen)

School fees, maize, some nails, a table with some chairs. This list is an accounting of how one woman in Siaya District, a mostly-rural area in western Kenya, used the approximately $1,000 given to her by GiveDirectly**. The innovative NGO simply donates cash, unconditionally, to poor individuals on the phone-based mobile payment system, M-PESA . They use it on whatever they believe they need most. A randomized controlled trial, the most robust and reliable study design, showed that GiveDirectly recipients disproportionately used the money on health and education and home durables – not on the tobacco and alcohol many development “experts” predicted. Those who received funds were, unsurprisingly, happier and less stressed.

The largest expense on this woman’s list is “mabati” – a metal roof. Previously, her home was made of thatch, which does its job pretty poorly. It looked something like this:

A home in Siaya district with a thatch roof. Thatch roofs are terrible at their job - they let in rain and need to be replaced every few months

A home in Siaya district with a thatch roof. Thatch roofs are terrible at their job – they let in rain and need to be replaced every few months. (Credit: Mike Miesen)

Now, her roof looks like this:


A home with a metal roof. According to everyone I spoke with, a metal roof is much better than a thatch roof, for a variety of reasons. Nearly every person I spoke with in Siaya district used GiveDirectly funds to purchase a metal roof. (Credit: Mike Miesen)

How many NGOs exist to provide sustainable roofing for communities? I can’t think of one. But every single individual I spoke with in Niaya district used at least a portion of their GiveDirectly funds on a roof.

This is not to say that the Against Malaria Foundation is doing a poor job. By all accounts, it is doing an outstanding job; it’s worth reiterating that almost everyone uses an LLIN as a means to prevent malaria. AMF is, along with the Schistosomiasis Control Initiative, the best counterexample to my argument***. But there are too few organizations like Spark MicroGrants and GiveDirectly, and too many that assume they know what is best for those they try to help.

*Here, I’m referring to immediately feasible means of preventing malaria. Eradicating malaria is feasible, of course – we did it in the states after World War II, using DDT – but difficult, and currently implausible (if not impossible) in much of the world. It’s a long-term fix; LLINs are a short- and medium-term patch. Other methods – like genetically modifying mosquitoes – are interesting but unproven for Anopheles gambie, the species that transmits falciparum malaria. And it’s unclear what the downstream ecological effects would be of eradicating mosquitoes in regions where they are native

**GiveDirectly is also one of GiveWell’s top charities

*** Also a top-rated charity by GiveWell, the Schistosomiasis Control Initiative (SCI) distributes de-worming pills to children in school

Is Social Enterprise For Cynics?

Typical pit latrines in Mukuru Kwa Ruben, an informal settlement in Nairobi. This is what the government provides for the people

Typical pit latrines in Mukuru Kwa Ruben, an informal settlement in Nairobi. This is what the government provides for the people. Social entrepreneurs can do better.

Charles Kenny, a Senior Fellow at the Center for Global Development, is one of the sharpest minds on international development and always a delight to read. But I found his latest article, on the naiveté and cynicism of social enterprise – which he pins mainly on Millennials – a bit off the mark.

In the article, Kenny argues that social entrepreneurs are naïve, anti-institution, anti-big business cynics who are improperly substituting small-scale solutions to massive problems that require massive solutions via a large, competent central government.

Kenny is absolutely right that modern infrastructure – roads, sanitation networks, electrical grids and the like – is necessary for long-term health, development, and growth, and that small-scale solutions aren’t perfect substitutes.

But his solution, such as it is, relies on projects that require years of work carried out by competent governments, and he fails to articulate a plausible medium-term solution that will improve the lives of the people living under incompetent governments now.

Kenny creates a straw man of a social entrepreneur who expects to replace the government’s role wholesale. In my experience, this is the aim of few, if any. Social enterprise is certainly not a perfect solution and it’s not a perfect substitute for large infrastructure projects; nevertheless, it holds promise to quickly, sustainably, and successfully improve outcomes and to (temporarily) alleviate suffering.

It’s worth clarifying what a social enterprise is. The most basic definition, while overly broad, is a good place to start: any organization, for-profit or otherwise, that uses market mechanisms to achieve a social goal. That’s it. In many states, a company can legally incorporate as a “benefit corporation,” a designation meant to protect the social aim if it’s in conflict with the goal of producing profit. Many for-profits choose to also apply for “B Corps” status, a stamp of approval that designates the business as socially and environmentally “good.”

In the article, Kenny refers mostly to smaller for-profit social enterprises using innovative technologies to solve a social problem. He argues that they are naive for thinking that using markets to solve global problems would have a significant effect:

Forget bureaucracies, charities, foreign aid, and big multinationals, they might say, the best way to fight global poverty is through the right blend of innovation and business savvy. In its own way, this is simply a new brand of naiveté. The fact remains that poor countries can’t develop without a big, traditional private sector that creates jobs, and the smartest innovations can only go so far without functional governments to provide basic services and infrastructure.

Note the straw man “they might say.” Why not just ask? Extreme poverty is important to end, but so are deaths from inadequate sanitation, improper health care, and a variety of social ills.

Kenny then argues that social entrepreneurs are not just naive, but cynical too:

The social enterprise movement is built on cynicism about the public sector and large-scale private enterprise. A recent survey of 12,171 people aged 18 to 30 across 27 countries found that while 68 percent thought they had an opportunity to become entrepreneur, only 45 percent believed one person’s participation could make a difference in the current political system. For cynics who nonetheless want to change the world for the better, social enterprise offers an attractive alternative to the snail’s pace of institutional change. With a double bottom line of profit and social impact—and the right killer app—social enterprises can innovate their way to a better world.”

Emphasis mine. Let’s set aside the fact that the data point above doesn’t say anything about how cynical Millennials actually are – if anything, 45% sounds pretty high! – and that “the social enterprise movement is built on cynicism” is, well, a pretty cynical claim to make.

What’s most important is that, as Kenny recognizes, institutional changes takes a long time. It’s hard to do, and harder to do right:

Fixing the infrastructure problems and low-quality health and education services takes more, better government—even if the services are contracted out. For all the valuable work they do, social entrepreneurs can’t replace the state’s role, and they can’t function nearly as effectively where governments are poor, incompetent, or corrupt.

Kenny is absolutely correct that an effective government is needed to fix the hard and soft infrastructure problems that plague low-resource countries.

But this won’t just happen tomorrow, or next month, or next year; building functioning institutions, water pipelines, and a health care workforce can take years. Faced with the choice of being outraged about inequality or getting to work, social entrepreneurs are choosing both.

The social enterprise model isn’t borne of cynicism; it’s the logical conclusion many pragmatists come to when large infrastructure projects take decades and when traditional aid and charitably fails to sustainably improve outcomes.

To see why, take Nairobi, Kenya’s gleaming capital city and one of the most developed places in Sub-Saharan Africa. It has a population of over three million, fully half of which don’t have access to piped water or a sewage grid. The pipes and the grid will eventually be in place – the plan is to build them out by 2030 – but until then the sanitation situation is a humanitarian disaster, especially for women and children.

IMG_6609 - Copy

Sanergy’s solution for the neighborhoods and citizens the government has failed

With respect to sanitation and clean water, Nairobi’s government has failed half of its people, and traditional aid projects have been unable to do much better. Seeing these failures, a few social entrepreneurs from MIT started Sanergy, an organization that developed a toilet and a business model to sustainably improve the sanitation situation in many of the informal settlements of Nairobi. It seems to be working. (I visited Nairobi to report on Sanergy last year; you can read the resulting article at The Daily Beast)

In my experience, social entrepreneurs don’t see their organizations as perfect substitutes for strong, effective governments and institutions; they see them as sustainable, reliable stopgaps that improve the lives of people now, while governments slowly improve. This doesn’t seem cynical; it sounds pragmatic and realistic.

The argument implicit in Kenny’s piece is that social entrepreneurs should stop wasting their time outside of the system and instead work within governments – or, at least, foment outrage to effect necessary change. This is impractical – most would not be effective agents of change in, say, Uganda’s Ministry of Health – and many entrepreneurs are entrepreneurial precisely because they don’t like working within the strictures of stodgy, bureaucratic institutions. And we must not forget that in too many low-resource and infrastructure poor countries, outrage and protest are met with violence and unlawful arrest.

None of this is to argue that social enterprise is the silver bullets that will finally rid the world of extreme poverty, decrepit infrastructure, and inadequate institutions. It isn’t.

Kenny is right: ending extreme poverty and deaths because of poor infrastructure will take competent, effective governments; massive investments in infrastructure projects that are maintained and improved over time; and consistent, well-paying jobs for the growing middle class.

And to be sure, many social enterprises are either ineffective or actively harmful. Most are too small to have anything resembling the sort of effect a government infrastructure project could have, and as governments improve some social enterprises will have to step out of the way. But there’s a role for social enterprises to begin to immediately improve health and education outcomes while governments shape up and prepare to do what’s necessary to lift their citizens out of extreme poverty.

Near the end of the piece, Kenny writes, “Cynicism about government is useless. We need outrage at its performance.” There is a place for outrage, sure, but it’s taxing and often generates more heat than light. Action is better.


Ebola is in the United States. Here’s Everything You Can Do to Protect Yourself.




9/30 UPDATE: A case of ebola has been identified in Texas. The post below was originally about two health workers who contracted ebola and were brought to the United States to be “treated” (to the extent that it is possible to treat a case of ebola). All of the advice still applies.

If you’ve watched the news in the past week or so, you’ve heard about ebola, a cunning virus with a high mortality rate (this outbreak: about 60%) currently rampaging through West Africa.

Now, it’s in America.

You may be wondering what you should do to protect yourself from this deadly, haunting disease:

  1. Nothing. Stop worrying about ebola in the United States. You cannot protect your family from ebola because it is not at risk from ebola.
  2. Donate to MSF or another organization working tirelessly to protect and save those actually at risk of contracting ebola, even as they’re attacked and vilified by scared, confused communities
  3. Get a flu shot and, if you have kids, make sure they have all of their childhood vaccinations

That’s it.

Foundation-Owned Social Enterprises: A New Way Forward? (My article at the Stanford Social Innovation Review)

Screen Shot 2012-11-27 at 11.54.58 AM

I wrote an article for the Stanford Social Innovation Review on Gradian’s unique business model, Foundation-Owned Social Enterprise:

A recent evaluation of the Rockefeller Foundation’s Program-Related Investment Fund concluded that it has “generated modest financial returns for the Foundation, contributed to investees’ financial sustainability and generated positive social returns on a variety of fronts,” and that “the Rockefeller Foundation has contributed to the rapid evolution of the PRI field for the last two decades.”

Program-related investments (PRIs) can be powerful social investment tools. They also take many forms, including purchases of passive debt and active equity. The health care social enterprise I work for, Gradian Health Systems, benefits from a very promising active equity investment: It’s wholly owned by a family foundation.

Read the rest here.

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 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

Designing Medical Devices for Predictably Unpredictable Environments

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

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

Via The Lancet Global Health Blog

(Full Disclosure: I work here, so am obviously an interested party)

Many remote hospitals in sub-Saharan Africa lack basic medical devices, like infant incubators, radiant warmers, and anaesthesia machines. Recognizing this, well-meaning individuals and organizations from high-income countries donate medical equipment – sometimes new, but mostly used – to these hospitals. Despite the best of intentions, this equipment often fails. Fortunately, social entrepreneurs and engineers are re-thinking medical device development in ways that could lead to real, sustainable improvements in health systems around the world.

There is no question that donated, used medical equipment has a role to play in strengthening low-resource health systems; it can better allow clinicians to provide life-altering, life-saving care to their communities. But, as Jane Cockerell, Chief Executive of the Tropical Health and Education Trust (THET), pointed out recently on this blog, the system must do better. (Her organization also helpfully produced a how-to guide for medical device donations). Roughly halfof medical equipment in developing countries – much of it donated – is inoperable or otherwise out of service. This is simply not good enough.

Medical device donations fail for a lot of reasons, but the main one is that medical equipment functions most effectively when it is designed for the environments it will be used in, and most medical devices used in sub-Saharan Africa don’t meet this modest bar. So they break – and often stay broken. Even when used medical device donations are thoughtfully executed, there’s a limit to how effective they can be. A MRI machine designed for an American hospital simply isn’t fit to adapt to the most common difficulties faced by remote, under-resourced hospitals in Malawi or Nepal. A power outage in America is a national newsworthy event; in much of Malawi, it’s a daily occurrence. An American hospital running out of compressed oxygen would be vilified, scandalized, and sued; a low-resource Nepali hospital running out of compressed oxygen is the status quo. When an X-ray machine needs maintenance or a spare part in America, a trained expert with a spare part is readily available; in remote, under-supported Malawian hospitals it’s difficult to find either.

And so, as painful as it is to see life-saving medical equipment sit broken, idle, or otherwise inoperable in hospitals’ “medical device graveyards,” it isn’t remarkable or even all that surprising. It’s actually kind of obvious: the equipment isn’t designed for that environment, so why would we expect it to work there?

Designing devices to meet the needs in which they’ll be used – call it “context-aware design” – isn’t new. It’s perhaps the central tenet of medical device design: Know Thy Hospital. In hospitals and health systems in low-resource settings, the customer needs flexible technology fit for predictable unpredictability. Sometimes the electricity is available; sometimes it’s not. The shipment of oxygen canisters may have arrived on time; it may be 2 months late.

My organization, Gradian Health Systems, manufactures and sells the Universal Anaesthesia Machine (UAM), a device designed to function continuously in any environment. It’s made to thrive in predictably unpredictable environments. When electricity is available, the UAM’s in-built oxygen concentrator supplies ample oxygen to the patient. When the electricity cuts out, the system uses cylinder/tank or pipeline oxygen; if that isn’t available, it seamlessly converts to room air (known as draw-over anaesthesia). The oxygen monitor will last up to 10 hours on rechargeable battery backup, providing integrated safety in a potentially unsafe environment.

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)

Crucially, the UAM is built for easy maintenance and repair, because that’s what the customer needs. With nothing more than a hex wrench, a screwdriver, and basic training provided during installation, the hospital’s in-house technician is able to diagnose most issues with the machine and locally source the necessary spare part. If he or she is unable to fix it, there will always be an in-country biomedical engineer who knows the UAM well – because we trained him or her.

My organization is only one of many to focus on context-aware design for difficult environments; to name just two others:

  • D-Rev created the Brilliance phototherapy unit, which uses LED bulbs that can last 25 times as long as a typical compact fluorescent bulb
  • Daktari designed a rugged, ultra-portable CD4 counter that can be used just about anywhere, allowing physicians to safely bring it to remote areas

Universities are helping to develop the context-aware design mindset in students, too.Rice University and Stanford University both have well-regarded programmes that have spun off a number of highly disruptive technologies that were designed with the end user in mind, including:

It is crucial to design medical equipment that meets stringent safety and regulatory standards set by national and international bodies, like FDA and CE-mark approval. Without adhering to these high standards, device designers run the risk of creating technologies that are “good enough for them” but not “good enough for us.”

Organizations like THET have done an invaluable service by documenting how to appropriately donate used medical equipment. But we must recognize that used equipment is, at best, a partial solution. It isn’t designed for use in predictably unpredictable environments, and for that reason it often fails. Proper design focuses on the needs of the customer – not the needs of the donor.