Solutions to Needs (alone) are Like Brussels Sprouts

Tags

design thinking, empathy, international development, marketing, poverty, socent, social entrepreneurship, social responsibility

Studying the Science of Marketing, there are three principles about which we learn early: need, want and demand. They are simple words and you all know their definitions. But, the relationship between them is critical when selling products to customers and, I would argue now that I’ve crossed over to the world of International Development, when giving away, subsidizing or selling products to beneficiaries. Let’s review:

need /nēd/ (noun) a requirement, necessary duty, obligation

want /wänt/ (noun) a deficiency, lack

demand /diˈmand/ (noun) an insistent and peremptory request

When we develop products to sell to customers, we often do research into these areas so that we understand what people will buy. It’s not necessarily logical. While most of the time, it’s easy to sell something that people need – like food, housing, or clothing. But, wants can dictate behavior that augments or changes the power of a need. It drives some of the credit crisis we face in America, someone may need to save, but they want to appear cool and so they buy a mobile phone, expensive clothing, or car. And just because a person needs or wants an object, he may not demand and actually buy it. He may want a to go on a cruise, but not have the money, the access or the will to do so.

This is true in fields of international development as well, people–rich and poor–are more similar than different in this regard (at least). A man may need food for his family, but he wants banana beer. A woman may want her children to be free from malaria, but since a bed net is too expensive for her to purchase on a given day, and saving her cash is difficult due to other needs, she will not demand or purchase one. A family living in a slum will demand a television, even though their children are still in need of education and healthcare.

All this is to say, that when individuals and organizations working in international development say they understand the needs of poor people, that isn’t enough. That understanding must be augmented with understanding their wants and their demands. We must spend the time to examine the desires that drive beneficiaries actions. Otherwise, the solutions may be like putting a plate of Brussels Sprouts in front of a five-year old hoping for chocolate ice cream; they might be what she needs, but good luck getting her to eat them.

In the absence of data

Tags

failure, missing data, pattern recognition

Our brains are designed to recognize patterns and respond.  So, when there is missing information, we tend to fill in the blanks.  But, our ability to fill in the blanks is based only on the history of what has happened, neither randomness nor radical change is taken into account.  That is, except when we will in the blanks with what we want to be true, even if that is counter to the patterns of the past, and especially if we have revised our memory of history to fit into the pattern of what we believe to be a truth.

Filling in the blanks in this way sounds analytical, mathematical, and even scientific.  But, it’s can also be thought of as telling yourself a story.  A story about what someone thinks about you, why something happened to you, or when/if you are ever going to get somewhere.

I do this all the time: at least every day, on some days every hour, and in some hours every minute.  Often it makes me seem smart, quick, intuitive…when I’m right. Often it makes me feel safe, assured, protected…until I’m wrong.

I challenged myself recently to try not to believe a story I told myself in a situation without data.  It was hard.  I had been able to ignore the first version of the story, and the second (which incidentally was radically different from the first).  But when story after story came to replace the last, I couldn’t hold out anymore.  I started to believe it was the truth and (because it wasn’t a particularly positive story) it hurt, just like it had really happened.  And then, it did really happen and it hurt again.

I wish I’d learned some sort of lesson from this latest experience.  But, I’m still processing it.  On one hand, perhaps filling in the missing data created a self-fulfilling prophecy.  On the other, perhaps by feeling the pain before it really happened, I prepared myself to hurt less.  I don’t know and by analyzing it too much, I’m just starting to tell another story.

It stings, like a slap in the face

When someone insults you, it hurts.  Even if you don’t believe it.  Even if it’s not based in data.  Even if you don’t like the person it’s coming from.  When someone insults me, it really hurts.  Mostly because it hits the on button of the critic that lives in my head who is insulting me all the time.  Do you know her?  Perhaps she’s friends with the critic in your head?  I like to think they have coffee on Thursday afternoons where they laugh at us.  Then I like to think of them choking on the coffee.

Anyway, I saw a blog today that hurt my feelings like a slap in the face.

http://www.eventuresincyberland.com/2011/10/video-clip-of-the-month-do-aid-workers-need-pr-101/

But now that it’s been 15 minutes and a walk around the block I can see her (Monica, twitter handle: @CyberlandGal) points.  Well, I can see some of them.  And they are valid.  My talk wasn’t perfect.  There were some factual errors.  It was my opinion based on conversations and not a proper research tool with a statistically significant sample size.  I knew that was going to happen before I did it (honestly I’m just glad I got through my 4 minutes without shaking).  I tried to correct the errors in the comments after the talk (you can see those here: http://www.ted.com/talks/amy_lockwood_selling_condoms_in_the_congo.html).  I’d love to do real research on this, but this is just my opinion.

And I respect her opinion, because let’s be honest, I certainly don’t think of myself as “jaw-dropping, informative, or inspiring” either.  But, I did start a conversation.  I did some research, wrote a presentation and put my opinion out there.  After the sting, all that is left to do is recognize that she did too.  My lesson about this is that not everyone agrees with me and I’m okay with that.  I’m even okay with the critics, because they can never be as harsh as I am to myself…and they may offer a different perspective that will help me to learn more, be a better communicator, and practice smiling in the face of the slap.

So thanks @CyberlandGal.  If you are free for coffee on Thursday, let me know.

People, places and things

Tags

assumptions, customs, international development, working abroad

When considering how to implement a program in a setting with which you are not familiar, it is important to find out how things work.  You’ve probably heard the story about Chevrolet launching the Nova in Latin America, not considering that the brand, translated to Spanish actually means “will not go,” which isn’t such a great message for a new car.  While this is an error of language, which seems obvious in retrospect, there are other simple assumptions that may cause similar problems in design and implementation:

- in many parts of the world names do not follow the given name and surname model, with the surname passed on from the father

- when there aren’t street names, there often aren’t addresses

- when employment isn’t reliable, neither is the place people call home, but there are often patterns in the times and places to which people move

- while mobile phones are becoming ubiquitous, prepaid phones mean that numbers are not always kept by the same person

- without a clock, one might not know the time and without a calendar, one might not know the date

- in some countries, the calendar is different from what we use

- federal holidays are not always announced in advance

- in some places white, not black, is associated with death

- different parts of the body are considered tantalizing in different places.  just because it’s acceptable for a woman to show her midsection, doesn’t mean that it’s acceptable to show her knees

I’m sure that other people have examples of customs and taboos and things that they have learned throughout their work experience and travels around the globe.  I welcome comments to share those here.

One thing to remember in all of this is that  we have all said or done things that weren’t quite right.  The most important thing is to pay attention to your surroundings and take cues from those around you to alter your behavior and change your plans when you learn something new.  Humility, an apology, and the flexibility to change plans can go a long, long way.

 

Luck and responsibility

Tags

luck, poverty, poverty line, responsibility

News broke yesterday that 46.2 million people in the US are living below the poverty line.  Now, the poverty line in America, is slightly different from places like say, Rwanda.  In the US, the poverty line is $22,314 for a family of four.  This is roughly $15/person/day.  By contrast, the international poverty line (as defined by the World Bank in 2005) is $1.25/person/day.  In this case, math doesn’t make this an argument worth having.  Something is desperately wrong in our country and getting worse.

My mom told me the story today of a woman she’d been seeing as she went to work at the train station in Chicago.  The woman, nicely dressed, held a sign saying she was looking for work as an administrative assistant.  She had resumes with her.  Commuters often stopped to talk to her and give advice.  Everyday she was there; pulled together, but seemingly at the end of her rope.  Until one day she wasn’t there.  We wondered together what happened to her.

It occurs to me, most days, but particularly today, how lucky I am.

In the years since we’ve been working in some of the most challenging places in the world, in terms of lack, I’ve been stunned by the simple fact that people don’t give up.  The human spirit endures, no matter what barriers exist in terms of access to healthcare, availability of education, or opportunities for economic development.  In the face of these experiences, I count myself lucky and have come to believe that with the luck of a privileged life comes responsibility to those who were born in less fortunate circumstances.

It took me a long time to come to this conclusion.  It was scary.  I had to admit that I was lucky and accept that I was responsible and that meant I needed to take action.  Now, if I’m not taking action, I feel indulgent, guilty and lazy. But that’s me, and admittedly I am a little over the top.  So, if any of this resonates with you I encourage you to do something.  Start small. Just start.  If that means dedicating your life, your free time, or the next interaction with someone in need, do it.  It turns out it feels good to take responsibility, just as good as it does to realize how lucky you are.

Africa: the country

One of my biggest pet peeves is when people refer to Africa like it’s a country.

“I’d really like to travel.  Where next?  Well, maybe India or Thailand or (sigh) Africa.”

I know it’s not my home.  Maybe that means I shouldn’t be so protective.  But, just like I will actually get upset if someone speaks ill of your mother, I get upset about this.  But, tonight I read the most direct and beautifully cutting essay about this issue, and the way that Africa and Africans are represented.  Binyavanga Wainaina, a Kenyan author, says it best.  So I’ll just refer you to him.

“A good head and good heart are always a formidable combination. But when you add to that a literate tongue or pen, then you have something very special.”  — Nelson Mandela

Let Me Down Easy

Tags

Anna Deavere Smith, Berkeley Rep, Charity Hospital, HUrrican Katrina, Kurtz-Burke, Let Me Down Easy

Warning: this one is a little graphic, please don’t read further if you are delicate or easily offended.

Over the weekend, I saw Anna Deavere Smith in her show, Let Me Down Easy, at the Berkeley Rep Theater.  It grabbed hold of me from the opening minutes and didn’t let go until well after the final bow.  If you are in the Bay Area and you think about death from a clinical or political or social perspective, it is a must-see.

The piece that ripped through me was Kiersta Kurtz-Burke, a doctor at Charity Hospital in New Orleans who Smith embodies by telling stories of medical training and providing care for patients in the aftermath of Hurricane Katrina.  Her description of an OB/GYN resident, with whom she worked as a medical student, giving a pelvic exam to a 13 year old girl with pelvic inflammatory disease (which makes the exam unbearably painful) is chilling.  He had ushered the girl’s aunt out of the exam room and when the girl screams in pain says, “what’s wrong with you? Surely you’ve had something bigger than my two fingers up there or you wouldn’t be in this situation in the first place.”

Although I know plenty of dedicated, empathetic and outstanding physicians, the lack of humanity described by this encounter still rings true for me and my experience of many in the medical profession and even in the development community.  And it galls me.

It was the most visceral description of the belief that somehow those in pain have created their circumstances.  That the poor have not tried hard enough, that the sick have not taken care of themselves, that the disenfranchised have alienated themselves.  That blame can be handed out.  And by placing it on the head of the person in need, that we have no culpability, can be distanced from it, and protect ourselves from experiencing the pain.

Later, Kurtz-Burke shares her experience of reaching the realization that the government wouldn’t be coming to the rescue of the patients and staff at Charity, the public hospital in New Orleans, even five days after the evacuation of private hospitals had started.  Her observation that it was only her, with her privileged background, who had not already experienced the denial of her existence and of her need, the patients and nurses were not surprised that they would be left to fend for themselves.  That had always been their experience.  The shame that brought Kurtz-Burke seeped through Smith and out into the audience and I experienced it as I had in watching the event unfold the first time.

I didn’t expect to be a part of the performance, to feel it so deeply, to feel the presence of the individuals who weren’t there in person, but channeled in spirit.  I was, I am and I do still.

Donating or Dumping

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Doc2Dock, donations, foodbank, Goodwill, medical equipment, MedShare, Robert Malkin, TED, Tina Rosenberg, Toys for Tots, WHO

Recently, I’ve seen a few interesting pieces about the wisdom of donating used medical equipment to the developing world.  The idea that it is acceptable and welcome to send one’s discarded or unwanted stuff (clothes, food, medical supplies. etc.) to those who have little is widely accepted.  Many organizations have taken this approach to address several issues.  In some cases, it works incredibly well, including: Toys for Tots, foodbanks, and Goodwill.  But, in all of these cases, these organizations have policies or procedures in place to insure that only high quality products reach the beneficiaries.

- Toys for Tots distributes only new toys because it is “legally not feasible to distribute dangerous or dirty toys” and because one of the principle goals of the program is to “send a message of hope” and “this goal cannot be accomplished through ‘hand me down’ toys.”(1)

- The Greater Boston Foodbank provides a list of the most desirable food items to donate and list guidelines for donations, including having “tolerance for expired foods but they must be no more than 3 months past expiration.” (2)

- Goodwill screens all donations against a system of quality and selection criteria and in addition to asking for items in good, working condition also have a list of items they will not accept. (3)  Given that these items are then sold, albeit at reduced rates, the market and customer preference also play an integral role in what reaches beneficiaries.

Criteria like are even more important when dealing with issues of medical equipment for the plain fact that these items are integral to life and death.  Moreover, programs that donate items to a foreign country, with significantly  different infrastructure and resource requirements and a different cultural context, must consider carefully the impact that donations may have.

The Tina Rosenberg’s commentary in the NYT online Opinator Blog highlights a few programs taking this approach.  The home page for Doc2Dock reads “Here we waste supplies, there they could save lives,” the organization redistributes the waste from US hospitals, including “unused, sterile medical supplies discarded for regulatory reasons and fully functional equipment.”    A similar organization, MedShare collect “surplus medical supplies and equipment from landfills and incinerators that, for various regulatory reasons, hospitals and medical companies must discard.”

In addition to wondering about the US policies that encourage waste, these programs bring up a few concerns, based on my experience in the developing world.  Practically, I wonder if the products that are sent are actually appropriate for the context in which they will be used.

- Infrastructure: Does it require constant electricity?  What if there are surges?  What does the plug look like?  Does it require water?

- Logistics: Does it require consumables?  Are those readily available? Are replacement parts available?  Are the products safe?

- Human capacity: Does proper use require training?  What level of professional is needed to use it?  Is that training available?  If it’s not used properly what safety issues may exist? Will anyone know how to fix it if it breaks?

A number of these concerns as well as the question as to whether these donations are impacting the market in the same way that clothing donations can (remember the 100,000 t-shirts controversy?) have been raised.  At TEDxChapelhill, Dr. Robert Malkin gave an interesting talk about how “donations hurt” focusing on these questions and the issue of lack of communication between donors and recipients and lack of accountability from donors   There is also a concern that perhaps these donations will prevent the success of local device manufacturing.  These are not new issues, and in fact in 2000 the WHO issued Guidelines for Health Care Equipment Donations that still ring true, highlighting four principles of a good donation:

1) Health care equipment donations should benefit the recipient to the maximum extent possible;
2) Donations should be given with due respect for the wishes and authority of the recipient, and in conformity with government policies and administrative arrangements of the recipient country;
3) There should be no double standard in quality. If the quality of an item is unacceptable in the donor country, it is also unacceptable as a donation;
4) There should be effective communication between the donor and the recipient, with all donations made according to a plan formulated by both parties.

While there is much good that can be done with donations, we must continue to be mindful about how they are done.  It is of paramount importance to create real partnerships in order to understand the context of the people and place, the needs and constraints of the time and situation, and to foster a long-term relationship in which dialogue exists to address the inevitable mistakes that will be made and issues that will arise.  This kind of work is not done when the contained is loaded, the ship sails, or donation arrives.  It requires commitment and collaboration in order to be successful.

 

(1) TFT 2006 Local Campaign SOP 10-2-06

(2) http://www.gbfb.org/donateFood/DonationGuidelines.cfm

(3) http://www.goodwillde.org/Donate_Goods.asp

Silver Bullets

Tags

Horn of Africa, hunger, malnutrition, micronutrient, Paul Farmer, RUTF, SAM, severe acute malnutrition

The world is full of complex problems, few of which have simple solutions.  And yet, simple solutions are the ones we, as humans, it seems like best.  People are overweight (or think they are).  How many buy diet pills, DVDs promising dramatic weight loss in 20 minutes a day, or pay for elective surgery to change their bodies?  I don’t know the figures, but it’s lots.  While some of these approaches are expensive, they are relatively fast and they don’t require dramatic changes in habits.  The idea is that with one pill or a few minutes or a little pain, one can get the results they want without the repetitive and constant hard work that a of changing their diet or adding more exercise to their lives entails.  People prefer the silver bullet.

It’s the same paradigm in development.

People are starving.  This happens all the time, but it something we are more aware of due to the crises in the Horn of Africa where people are living in refugee camps and reliant on food distribution programs run by UNICEF, WFP or USAID.  These programs are doing what they can, but as we address the crisis, we also must think about how we got here.  What causes famine? The problem is dire, and also complex.  Hunger is caused by a lack of food, which is caused by lack.  Lack comes in many ways: land, knowledge of efficient agriculture practices, resources to purchase quality seed, availability of irrigation, access to information about pricing, policies to support trade, transportation to markets, storage…and it goes on.  The lack of food that causes mass hunger isn’t something that can be solved with a silver bullet.  But we try.

One solution that has been touted as a silver bullet to hunger recently is RUTF (ready to use therapeutic food).  This magical concoction of peanuts, milk powder, sugar, oil and micronutrients can transform a severely acute malnourished (SAM) child into one with more than a fighting chance in 6 to 8 weeks.  No doubt, it is amazing.  But, this product is not a solution to mass hunger and we need to be careful about the way it is used so that we don’t ignore the underlying problem and inadvertently cause even more problems.

Things we need to remember about RUTF:

It addresses a very specific condition: severe acute malnutrition in which a person is more than two standard deviations below the appropriate range as measured by MUAC (mid-upper arm circumference).

It is expensive: $60 for the product alone for a 2 month supply

It requires a functioning supply chain: from production to port to community, including storage facilities for heavy and bulky

It requires a community-based management program with healthcare trained and provided the resources to identify children with SAM, teach their caregivers to administer the medication at home, and follow-up with the families.

And, most important, RUTF is not food.  While it does play an important role, it is not the silver bullet to the issue of hunger.  As the wise Paul Farmer once told me, “food is the solution to hunger.”

Polarity

Tags

balance, public speaking, TED

I was lucky to be invited to attend and speak at TED Global this year in Edinburgh.  Well, let me be clear…I applied and was accepted, twice.  It’s not like I was plucked from the sky or found like a shiny penny.  I asked for this.  Even knowing this, I was extremely nervous about my talk.  Please don’t tell any of my past professors or current supervisors, but I don’t prepare much for the speaking part of public speaking engagements.  Generally, I put together a presentation, which is steeped in data, so I know the information backwards and forwards.  Add a little of the ham and cheese of my personality and data stretches to become a little entertaining.  For this gift, I am certain I have my great-grandfather (my father’s mother’s father) to thank, as he was a politician and circus showman.  But, still I was nervous.

I practiced my 4-minute talk at least 30 times.  I timed it, I cut pieces, I added details.  And, it went well.  Which, is and was, an awesome feeling.  Strangely though, despite the high of the achievement and the kind accolades from the audience and my friends and family back home, I recognized a deeper and darker emotion present as well.  At first I thought maybe it was just the hang-over from the high.  But, it’s persisted and in the last 24 hours I’ve come to know it better.  Despite basking in the light of praise, having fulfilled a lifelong dream, and embracing a confidence in my intellectual capabilities, the darkness of the second-guessing, sadness that I am not connected, and the fear that I will always be alone persist.  And while I feel a little silly and am concerned that I sound ungrateful, I have to acknowledge the polarity of these feelings and their common existence.

I wish there were someone or something that could make me feel better.  And there is, but it’s just me and the prescription is easy, but challenging.  It’s not that there is something wrong or anything to fix, it’s just acceptance.  Accepting what I feel, accepting what I’ve done, accepting who I am.  Accepting the constant polarity of how I experience those things and, I hope, bringing a balance between them.