making hope visible

Spending the weekend in New Haven, Connecticut, at the Unite for Sight Global Health Conference. There have been so many great conversations centered on healthcare in the developing world, and I’m sure there are more to come, but one thought on design for the developing world.


Michael Fairbanks of The Seven Fund told us earlier that with one question, he can predict the economic prosperity of a nation for years to come. That question is “Do you believe in competition?”

Unfortunately, the global health contingent, and subsequently, this conference, is being driven by nonprofits and by medical professionals. Those groups are necessary and much-appreciated - we need people focused on policy, on aid, on one-on-one patient care. But the real innovation, the sustainable developments that will change a country, come from industry. They come from the translation of the research into practical products.

Out of 2,200 attendees, the vast majority are medical students, undergrads, and nonprofit managers. But, industry and entrepreneurship are taking a stand. There are numerous examples of for-profit enterprises who are seeking to be socially responsible in their mission, and industry posing smarter questions in how to make our models work for more people in the world.

The game has changed. It’s no longer “Is there a fortune at the base of the pyramid?” The question has been fundamentally reframed, if even by a small group of people, to ask, “How can we create a fortune with the base of the pyramid?” Corporate social responsibility is no longer adequate, and industry is slowly but surely, rising to the challenge.

We don’t have the answers yet. We don’t know exactly where to take it. But the questions we’re asking are making hope visible this weekend.

one day without shoes is tomorrow

I take pictures of my feet when I travel. As I was looking through the One Day Without Shoes materials for tomorrow, I realized how many pairs of shoes I own / have owned. To be fair, my mother and I wear the same shoe size, and she’s not exactly shoe-deprived. But it’s strange to put our joint shoe collection in direct juxtaposition to children in the developing world who have never owned a pair of shoes.


Rockin’ a pair of Toms in Jackson Square, New Orleans, Louisiana.

Tomorrow, April 5, Toms Shoes is sponsoring their One Day Without Shoes, a campaign to raise awareness of the millions of kids in the world who have never owned a pair of shoes. I know most of you have heard of Toms, but for those that haven’t, it’s a socially conscious for-profit enterprise that donates one pair of shoes for every pair bought to kids in the developing world.

But the coolest part is not that they donate the shoes - it’s that the shoes that they donate are custom-made for the children they’re going to. They aren’t giving people what they can make. They’re listening to what it is that people need, and making shoes accordingly. In a world where companies often focus on what their “core competence” is, and what the adjacencies to that space are, Toms is making shoes that people in the developed world want to wear, and shoes that people in the developing world need to wear.

Tomorrow, when I’m not in the lab or the prototype shop, I’ll be working without shoes to let people know about the millions of children that walk miles to school without shoes on. I’ll be lasershowing without shoes to remind people that kids are dying every day from soil-borne diseases that are entirely preventable and require little more than a covering in high-risk areas. I’ll be errand-running without shoes to let people know that in some parts of the world, shoes are a status symbol that keeps children out of school when they can’t afford to meet the dress code. What will you be doing without shoes to bring awareness to a child in need?

the hospital doesn’t have to be a place where they go to die

If you want to understand a culture, listen to the stories that it tells.

MedShare is an organization that turns stories of despair into stories of hope. They donate discarded or surplus medical supplies from hospitals and companies to hospitals that have requested them in the developing world.


During our volunteer session this evening, Lindsey told a story of a hospital in Nigeria that was able, for the first time, to perform a c-section on a woman in labor due to the supplies that they had obtained from MedShare. Afterwards, the mayor of the town threw a party for all the surrounding villages to celebrate the milestone:
“It wasn’t just that this one woman’s life got saved. It was hope for the entire village. If something ever went wrong, there was a place they could go for help. And the hospital doesn’t have to be a place where they go to die.”
Sometimes, it’s amazing how one small thing, can change the stories of a people forever.

the difference between health and public health

For the second time in two months (and despite getting a flu shot), I’m sick. This is strange for two reasons; the first being that I grew up in a developing country and have an immune system bolstered by 1+ billion people living in an area smaller than half the United States; the second, because I’m a relatively healthy individual who exercises regularly, doesn’t (didn’t used to) get sick often, and maintains a fairly healthy diet (sleep schedule notwithstanding).


(photo courtesy of… )

If I had to guess, I picked something up at work. Because workplaces, like elementary schools, are incubators for illnesses. It’s all fine and well to be a healthy individual with a strong immune system, but throw that healthy individual into a building for 9+ hours a day with others of varying immune capabilities, and it makes no difference how healthy they were to begin with. Essentially, I need my coworkers to stay healthy if I plan on staying healthy, and I derive a very real benefit (in economic terms, an externality) from my team not being sick.

That’s the difference between health, and public health. Healthcare, like education, provides benefits not only to the individual that purchases the good, but also externalities to others in society such as increased productivity, lowered disease transmission, and reduced microbial resistance to medication.

Here’s the real kicker (and especially in the context of healthcare reform): if all of society derives these benefits from me not being sick, who in society deserves to pay for my health? We’ve managed to answer that question in education - society pays to educate its children because society benefits from an educated population. Should society be paying for healthcare when that society derives benefit from a healthy population?

And let’s take it one step further. In the developing world, individuals cannot afford to pay for the most basic of health services. In these places, though, because of the prevalence of infectious disease, keeping individuals healthy delivers huge impact to others in the population. Globally, preventing an outbreak of infectious disease in Niger means a smaller chance of a compromised population in Atlanta.

So, today’s good question: who should pay to keep people healthy?

a few statistics in global health

Last Friday Massachusetts General Hospital’s Center for Global Health had its first annual symposium. It was an incredible turnout - at least 300 or so were in attendance. Lots of good thoughts as I try and wrap up my research paper, but one in particular:


(photo courtesy of MedShare - if you live in Atlanta and don’t know about MedShare, you need to volunteer)

I posed a question to Kris Olson, who is a pediatrician and doctor of internal medicine at Mass Gen, and also the Director of the Global Health Initiative for CIMIT, about public-private partnerships and how we make innovation for the developing world a sustainable venture for the developed world. He didn’t have an answer (no one does, and even now, only a few people are trying to figure that out), but he did bring up some interesting statistics and the need for healthcare innovation:

~ 40% of needles used to vaccinate children in developing countries have been used in another child before
95% of medical equipment (what we call “durable medical equipment”, or DME) in resource-limited areas is donated equipment
90% of those devices fail in the first five years

Dr. Larson, while acknowledging the need for innovation in the space, made a great point: “A need does not necessarily equal a market.” Not sure if we can find a way around that, or create a market, or develop a nontraditional market, but answering that question and monetizing that market goes a long way to improving global health in all regions of the world.

how can we design to inspire self-efficacy?

I went to a talk yesterday by Josh Chuzi for Atlanta Design Week called Healing Environments: How Art & Design Can Improve Health. Although the context of the conversation came from his background in art history, he posed a very interesting question: how can we design to inspire self-efficacy?

The World Health Organization defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Chuzi talked about healing as a multifaceted term as well, highlighting not only physical healing, but psychological, spiritual, social, cultural, and sexual healing as well. The common theme in healing, though, is to build (and I don’t love this term) self-efficacy.


(thanks, Wikipedia)

The prevailing attitude in the healthcare environment today is to treat the physical body. According to Maslow’s hierarchy of needs, we must address the physical, corporal needs first. I think, though, sometimes in the current state of healthcare in the world today, we take that need out of proportion with the others. As a medical device designer, I see that we certainly think first and foremost (and sometimes solely) about how medically efficacious a device or therapy is. While that has to be our primary concern, it often becomes our only concern.

We lose sight of the human element of healing. The need to feel nurtured, stimulated, and protected - emotional self-efficacy. The need for our family and friends in times of medical emergency - social self-efficacy. So how do we inspire patients and clinicians to strive for that?

And even more importantly, how do we inspire patients and clinicians in the developing world to achieve that goal as well? In places where empowerment is in short supply, how do we create products and processes to drive people to total self-efficaciousness?

Clever design takes these things into account. That’s why music videos in India work wonders on rural literacy rates. That’s why Paul Farmer’s DOT program was such a success in Haiti. And why Greg Mortensen is able to effectively counter the Taliban’s madrassas in northern Pakistan and Afghanistan by building schools.

No, clever design can’t do this on its own. Empowerment and self-efficaciousness are a partnership of people, product, and process. I suspect that in the next 20 years in this country, we’re going to see a dramatic shift in how doctors see patients. As costs continue to rise, we’re going to have to. The process by which we pay for healthcare will change. And the products that we use will have to adapt to keep up. Health is about a whole person. While the medical profession is segmenting and specializing further, the processes and products that we use have to be able to synthesize those specialities into a whole person again.

how information moves to create empowerment

Late last year I met with some folks in Boston who are working on some neat emerging technologies for diagnostics in the developing world. Since then, we’ve all been trying to brainstorm ways to engage others who are interested in this topic into the conversation. Recently, Aaron posed a really interesting series of questions to me in thinking about the world after their diagnostic technology becomes widespread:


(photo courtesy of… )

“How does the data move; what is done with the data when it gets there? How does it influence caregivers, governments, funding sources, etc? Can we predict what we might learn?”

I have an endless curiosity for questions like these (as Thomas Friedman calls it, this is my “inner fire truck”). Although my design skills are still in their infancy, and I hopefully have a long road in global health and technology ahead of me, these are the best kinds of questions to ask to move further down that path. Essentially, development is about empowerment, and empowerment comes from information. When you design for the developing world, and with the developing world, the primary concern is access to information. What information do these people need to make appropriate decisions (and how does that differ from the information that we provide for traditional devices in domestic hospital settings)? How can we deliver that information in a usable and readily accessible format? What will happen to that information once we obtain it? What other things can we couple it with to make the most of it?

Of course, you have to optimize your physical design for the environment that it will be used in, but these are questions of design intent, and they’re far more interesting than questions of form or function.

she would give her life to preserve that kind of trust


(Dr. Muhammad Yunus and myself, bright and early this morning)

 I dragged myself out of bed at 6 am to attend a small lecture and meet-&-greet with Muhammad Yunus this morning. My academic background is in both biomedical engineering and development economics, and Dr. Yunus is a huge force in poverty eradication. The Grameen Bank is wildly successful, and incredibly simple. He spoke for a little more than an hour, off the cuff, and had some really great stories to tell. One of the most vivid, though, was about Grameen’s vision of having 50% of its borrowers be female.

When they first started in the 1970s, Yunus and his students went to the villages themselves. He would wait outside under a tree and his female students would go inside and talk to the village women. When the students had a question, they would come outside, discuss with Dr. Yunus, and go back inside to the women. For years, the women were so reluctant to borrow money. They heard things like, “My husband deals with the money.” and “I’ve never even held money in my hands.” and “I don’t know what a bank is.”

Imagine – how do you explain to an illiterate village woman who has never held money, what a bank is?

Furthermore, how do you explain this to a woman who, all her life, has apologized for the fact that she was born a woman? She has been called a drain on her family, she has never gone to school, and she is expected to manage a household with whatever she is given by her husband. Her life is not her own doing. This is the culture, the history, the circumstance that surrounds her life. How do you peel back the layers of fear and convince her to take a chance… on herself?

It took six years of convincing women like this for the Grameen Bank to achieve its 50/50 goal. That is, in the grand scheme of things, a very short time, but imagine giving six years of your life to walk around villages and convince women to build a better future for themselves and their families. That is no small investment. Yunus, when reflecting on the achievement, said this:

“A woman comes to the bank after days, weeks of pondering. Can she do this? What if she fails? Her family will forever hold her responsible, blame her for any mistakes. But she knows she wants a better life for her children. So she takes this sum of money - $30, $40, $45. It’s a larger sum than she’s ever seen. For some, it’s the first time she’s ever held money in the first place. That woman is reduced to tears by the amount of trust that someone has placed in her. And she would give her life to preserve that kind of trust.

Repeat that story 8 million times, and you will understand what Grameen Bank is all about.”

A call to those of us who have been lucky enough to “win the lottery of birth” - It is possible to eradicate extreme poverty in our time. It is possible to improve healthcare in the developing world. It is possible to stamp out disease, to ease suffering, to empower women. All of these things are achievable. They require us, though, to take chances. To peel back layers of fear. It’s not about making money. The Grameen Bank is profitable. It is not charity. It is a business. But the goal is not to win the game of business – it’s to solve the problems in people’s lives.

A woman came back into the Grameen Bank several years after she repaid her loan. She had built a successful enterprise in her village, and had managed to send all of her children to school. That particular day, Dr. Yunus was in the bank, and she came by with her now-grown daughter. This woman could have asked her daughter to stay at home and help with the business while her sons went to school, could have pulled her child out of school because she needed the help. But she didn’t. Her daughter was now a practicing doctor in a city in Bangladesh. These two women stood side by side. They looked the exact same, except the difference in age. And while he was talking to them, he couldn’t help but think – one woman, illiterate, uneducated, took a chance and made some sacrifices. The other woman became the product of those chances and sacrifices, and was now given the chance to save other peoples’ lives. Her mother could have done everything that her daughter got to do, if only society had given her the same chance.

the fallacy of the empty vessel


(photo courtesy of… ) 

 “In the Yucatan peninsula, it is the local collectivity of Mayan women who hold authoritative knowledge about birth; that is to say, the knowledge that is considered consequential for making decisions about and managing the event. Childbirth takes place either in the woman’s own house or that of her mother and technologies are familiar household objects. There are unquestionably experts involved: a midwife, with extensive experience of many births, supported by other women of the family, each of whom has her own experience on which to draw. But moment by moment knowledge of the event is produced collectively by the participants and draws centrally on the authority of knowledge of her own body granted to the woman herself. 

Into this system, designers of development programs to promoted Western biomedicine introduce new technologies developed in the context of the high technology hospital. A case in point is the sterile scissors, introduced as an alternative to the local practice of burning the umbilical stump with a candle to prevent infection. The gap between the context of its design and the local conditions of its use (in particular, an absence of stoves) led to a reinterpretation of the technology from a sterile scissors to a pair of scissors dipped briefly into a bowl of hot water. Observation by traditional birth attendants of a subsequent increase in infant tetanus resulted ultimately in their rejection of the scissors in favor of the former, clearly more effective practice of cauterization.”   - Chapter 7: Computerization and Women’s Knowledge | Suchman & Jordan, 1988

The gap between the context of its design and the local conditions of use – there isn’t a more powerful statement in the eyes of a designer. The single most important answer one can seek when developing a new technology is answering the question of use case – where will this technology be used? By whom? In what environment?

Suchman and Jordan go on to describe the “fallacy of the empty vessel – the belief by those who design new technologies that there is nothing there in advance of their arrival.” It’s an interesting point - we aren’t designing for an environment which has nothing. We are designing for an environment that has something different than what we have.

These two thoughts together define the crux of the difficulty of designing for the developing world – determination of the use case by people who aren’t well-versed in the context and circumstance of the users they are designing for. In other words, how do I, with my middle-class, relatively healthy, immigrant-turned-US-citizen background, translate my background in engineering into meaningful designs for people who need it most? There has been criticism among the larger NGO community of the “helicopter designer” – those who come in without understanding the use case and drop in a technology that isn’t well-received and doesn’t build trust or collaboration between the parties, and then leave. But there’s also the reality of both an inadequate critical mass of native designers and engineers coupled with Brain Drain of those who do specialize in those fields. With every failed innovation that gets transplanted from a disparate use case to one in the developing world, we lose credibility and trust in the eyes of those who we meant to help.

The world has a long way to go to address all the health challenges that we face, and we have a collective responsibility to improve the quality of life of people everywhere. In the short term, that means developing technologies that cater to the populations who need them. In the long run, we need to empower people to develop those solutions on their own. As we develop, then, it becomes crucial to do so in a way that builds trust and fosters partnership between those who design and those who use.

inventing for the future consumer

“Think one hundred years in the future, and ask ‘what will people wish we had done?’ ”
I first read that quote when I was waiting for a meeting at the Centers for Disease Control in Atlanta. It’s posted on the wall behind the Smallpox Eradication exhibit, and attributed to William Foege (who is something of a legend in the global health world). Reading that statement, it’s hard not to be excited about the work that lies ahead for me. In fact, that exhibit and the ensuing conversation inspired my research during my last year at Tech (for those that are interested, since I allude to this a good bit, the title of my working paper is “Defining The Process of Innovation: Common Themes in the Development of Biomedical Technologies for the Developing World”, advised by Thomas Barker in the Coulter department of BME at Georgia Tech).

As many of you know, I design. Specifically, I design medical devices, and although my work doesn’t yet cater to the developing world, it is nonetheless challenging and often frustrating to design for future consumers. For one, current consumers don’t know what they want or need. Henry Ford once said, “If I had listened to my customers, I would have built a faster horse.” Market research has a place, don’t get me wrong, but as I’m finding out now, the feedback you get from the market is more a blur of mumbled whispers than it is a conclusive cry of need.

Given the confusion of customer opinion, it’s frustrating to balance the need of the current user with the pressures of the future marketplace. The more removed you are from your user, the more difficult this gets. When you’re dealing with consumer goods, you’re designing for an everyday person not dissimilar from yourself, and your release cycles are typically short (less than a year) – and your feedback is still mixed. When you get into more complex markets, such as healthcare or aerospace, you’re designing for more than one user, and often a purchaser that’s entirely separate. For example, when I design a device, I consider the user (a clinician or nurse), the object of use (the patient), and the purchaser (a hospital GPO or contract manager). Add that to a release cycle of 18 to 24 months minimum (without clinical trials), and you can see how challenging this gets – trying to predict the preferences and needs of three distinct use profiles at least two years in the future in the face of rapidly changing technology.

I wish I had more insightful commentary on how to do this. It’s been a focus of mine for a while, as a young engineer trying to learn all that I can about customer preferences and how to meet needs through design. Designing for people in the future is something I’m struggling with – heck, designing for people in the present is challenging enough right now. Tim Brown of IDEO suggests “structured brainstorming”, but I think that it also requires a leap of faith, and in some ways, younger designers who better relate to future consumers are at an advantage, especially those that are scripted in systems thinking.

Maybe I should have been an imaginary engineer after all.

(and sorry Shan, for a post without a picture)

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