Good Intentions Gone Efficient

Sitting in the front seat of a white government issued SUV, I felt sick to my stomach. Two of my teammates sat behind me joking with Dr. H, a well connected health official, as we rumbled between two South Indian villages. It felt like something out of a movie – foreigners wearing sunglasses arriving to a host of curious looks. I tried hard to put aside the misgivings I had for the time being. At each stop we were graciously accommodated - bodies whirling around us preparing tea as doctors dropped everything to answer our questions. Yet, it felt far from traditional Indian hospitality.

Maybe it was the looks in their eyes, or the urgency with which they moved, but it quickly became clear that the staff was afraid of something. Behind us our host barked orders, apparently using our visit as an opportunity for an inspection of the facility. I bit my tongue as the janitor hung his head- presumably being told in Kannada that the floor was not clean enough. Eventually we received news that a baby had been delivered earlier that morning and Dr. H shepherded us into a makeshift recovery room.

The new mother laid with her child as her family watched us from neighboring beds. Dr. H paced around asking questions and noting the quality of the room. Our eyes drifted to the squirming hours old baby. My heart sank when our curiosity was noted and we were prompted to touch the newborn. Here we were on what should be one of the new family’s proudest and happiest days – strangers barging in and being asked to treat their child like a hands-on experiment. My discomfort was visible, but our host insisted. I eventually touched the poor thing’s head and hustled out of the room. Dr. H teased me and we moved on with our day.

I couldn’t put the experience behind me. Images of the day kept flashing through my head- the vacant looks on the faces of patients in the crowded waiting room as the doctor left his post to meet us, the embarrassment of another clinic’s staff when Dr. H pointed out a error in their tabulation of the month’s deliveries, and my silence throughout the whole ordeal. I had come to India to help people, but had I really spent the day doing the opposite?

That feeling stuck with me for longer than I expected. While the three of us had spent the day with Dr. H, one of our team members stayed back in Hubli to troubleshoot our technology and do other some other work. Over the past week our team had researched something called Samastha, a HIV/AIDS program funded by USAID and an organization called KHPT that our NGO was responsible for implementing in Dharwad District. Eager to gain a perspective on the finer details and goals of the program we decided to email two contacts listed on a PDF document we had found online. The responsibility of writing the email fell to Jon as we toured the clinics.

The email read:

Hi Ms. Shankar and Mr. Gurnani,

My name is Jonathan Goldford and I am part of a team from the University of Southern California. As a group of four we are working with the Desphande Foundation to improve the efficiency and effectiveness of the Samastha project at BCT in Dharwad. To do this, we are implementing a simple SMS-based healthcare communications network using software called FrontlineSMS.

Once we have completed the project we hope to be able to scale it to each of the other NGO's in the Samastha project. It would be great if we could set up a phone call with you to discuss our project and the potential to work with the other NGOs in the future. Thank you and I look forward to hearing from you both.

As we later found out, the message was a textbook error for several reasons. First, we had unintentionally reached out to two very high up officials. Despite the relative ease of obtaining their contact information we were later told, “People don’t just email them.” The best description of communication in India I have heard since is that in this country things are “well stratified, well channelized”. The status of the two individuals made the informal tone and greeting of “Hi” unacceptable. Worst of all, we had used the terms “efficiency and effectiveness” – two words thrown around American business communication that had been misunderstood in this instance to mean we were calling their program inefficient and ineffective.

The message would later prove to be a bold, but brash gesture. The introduction we were trying to make for ourselves was independently made by a Deshpande Foundation program officer the very next day. When he received a call later that afternoon he assumed it was in response to his request for a meeting, but instead it was to admonish him for our communication. It quickly became clear that we had made a mistake that jeopardized not only our project, but our relationships with the Foundation and our partner NGO as well.

The next day the possible consequences were presented as such by our mentor, Rahul Brown:

• You will be spending the remainder of your vacation in America
• You will be reassigned to another project
• You may be able to salvage your project with another NGO, but you will need to work 12 hours a day, 7 days a week.

Oh, and we were told that it was more than likely that our partner NGO would lose its funding from the organization we had contacted. Our emotions at the time were many – disbelief that a harmless email could cause such damage, frustration that we ourselves were unable to do anything to rectify our actions (we were put on “communications lockdown” and referred to as “grounded”), and fear that the friendly staff we had grown to know would be out of the job.

Yet, today our project continues. We enjoy a healthy relationship with administrators at KHPT (the organization we emailed). In fact, we met with one administrator today to make an introduction to EXPAND our project in the future and another requested a PowerPoint of ours yesterday to take to a meeting in Bangalore. So how did we get from the dire straits described above to where we are now? The short answer is, I don’t know. The apologies we showered on the affected parties were laughed off, administrators whose relationships we had supposedly strained behaved like old friends, and after a long lay-off our project emerged stronger with important people supporting it. The full story involving exactly who reacted and in what way, and other critical details have not been shared with us and likely never will.

I still think about the incident amidst our now demanding project's activities. New information emerges every day and with it new theories – for instance, that our affiliation with a US university combined with the American government’s funding had led some to believe we were contracted to evaluate their program without their knowledge or consent. Most read the text of the email and can’t believe our stories – a high-up staff member at Deshpande even told me recently that he thought it was a good email. Most often I think about the ubiquitous Samastha program banners. In small print beneath the USAID logo it says, “From the American People.” Wasn’t that our intention as well? Where had I gone wrong? Where had we all gone wrong?

In the end, I've given up explanations in favor of something Gandhi says in his autobiography:

“Numerous examples have convinced me that God ultimately saves him whose motive is pure.”

- Dan

Power Law, Sex Workers, and HIV/AIDS

After 12 agonizing days our project is back on track! Unfortunately, I'm going to delay telling the back story of our lay-off yet again. Hopefully the suspense is building - I hope we don't disappoint when the time comes!

In the meantime, our project has developed a clear direction - employing a FrontlineSMS system
around the Bhoruka Charitable Trust’s HIV prevention programs. BCT is part of a larger network of organizations working in a comprehensive HIV program. They implement the preventative side of the equation- including outreach, education, referrals for testing. BCT focuses almost entirely on high risk populations- mainly sex workers. But why sex workers? What about everyone else?

I spent one of my off days powering through Malcolm Gladwell's Outliers - a very interesting study that attempts to explain extraordinary people. Gladwell is a great writer for a number of reasons- including his gift for turning complex streams of information into a narrative. His writings also get the user to question closely held assumptions and do something we often don't stop to do - think. Since Gladwell got me thinking, I'd like to attempt to do the same for you - explaining the pilot use of our project (including the question of “Why sex workers”) in the context of one of his writings - a New Yorker article from 2006 called "Million Dollar Murray" (accessible here)

I’d recommend reading the article, but I’ll try to summarize as best I can. Gladwell believes that we have a tendency view problems ranging from homelessness to HIV as “normally” distributed. He explains what he means by this using the LAPD’s issues with racism and violence following the Rodney King riots:

In the language of statisticians, it was thought that L.A.P.D.'s troubles had a "normal" distribution— that if you graphed them the result would look like a bell curve, with a small number of officers at one end of the curve, a small number at the other end, and the bulk of the problem situated in the middle. The bell-curve assumption has become so much a part of our mental architecture that we tend to use it to organize experience automatically.

In fact, the opposite is often true. Problems like violence at LAPD can be said to follow something called the “Power Law”. The problem is not in the middle, but rather at the extreme. Gladwell claims that a small population accounts for the majority of the costs associated with homelessness (the namesake of the article is an individual from Reno named Murray who racked up over a million dollars in hospital expenses over 10 years!). The optimal solution changes the minute you begin to envision problems as following a power law distribution. In the case of homelessness it became rounding up the chronically homeless population (read: the long tail) and offering them a free apartment and intense case management.

Now try to envision HIV/AIDS as following a power law distribution. What if you focused on the population that accounted for a large proportion of the infection’s spread? Turns out that some visionaries in Thailand did just that (read more here). While other countries were spending vast resources on Anti-Retroviral Drugs (ARV’s), Thailand invested its funding in prevention programs- including interventions with the country’s sex worker population. Describing the “100% Condom Program”:

This program aimed to enforce consistent condom use in all commercial sex establishments. Condoms were distributed free to brothels and massage parlours, and sex workers and their clients were required to use them. Brothels that failed to comply could be closed. Without this program, it is estimated that Thailand’s national HIV prevalence would be ten times higher than it currently is.

Sounds pretty familiar right? Thailand has been able to reduce its number of new HIV infections from 143,000 in 1991 to 19,000 in 2003. The same cannot be said of countries in Sub-Saharan Africa that did not pursue this approach.

For some this may still feel wrong. Power law solutions often don’t. One doctor here expressed his frustration with the response of NGO’s here. He believed that everyone should be tested for HIV, not just high-risk populations. There is also a moral hazard here - why not just shut down the brothels all-together? why should we spend tens of thousands of dollars housing a few select homeless people?As Gladwell puts it: “Power-law problems leave us with an unpleasant choice. We can be true to our principles or we can fix the problem. We cannot do both.“ It’s worth noting that Thailand combined their targeted interventions with a massive public information campaign and other initiatives.

After meeting with sex workers here and listening to their diligence surrounding condom use and HIV/AIDS it’s hard to deny that important progress is being made. Our hope is that a FrontlineSMS system can build on the success of this and other programs. Who knows what lessons we may learn.

- Dan

FrontlineSMS for Healthcare, Genesis

Several times since we have arrived in Hubli, people have inquired about how our project began, so now I would like to take the time to recount the tale.

Two of the people I lived with this past school year, Alex John and DJ Strouse, were amongst the participants of the University of Southern California Steven Institute for Innovation’s first Global lmpact Program (GIP) (see their project’s blog here, last year's group posts are the earliest entries). Last summer DJ, always challenging me intellectually, recounted the lessons he learned while working in Hubli and I followed his team’s blog sporadically. Fast forward to November 2008. DJ Forwarded me an email regarding a brainstorming session for the upcoming summer’s second GIP. During the session I remember feeling confident and hopeful- here was a program that sought to bring students together to spearhead projects that would have a sustainable social impact.

After that initial meeting with my future Global Impact teammates I knew I was interested in the program- an all-expenses paid (minus the cheap cost of food and leisurely travel) trip to India would allow me to truly explore my socially innovative potential. I thank DJ for being what I now fondly refer to as “my catalyst”. He encouraged me to apply for the GIP and as soon as I began to show an interest in diving into the world of social development he met me head on, always offering me a challenge and his extensive knowledge of that world, which he had been pursuing as a potential life path before he discovered his love of physics.

Because it was not initially clear whether GIP member selection would be based on initial project proposals with self-made groups or selection through individual applications, and because I studied Biological Sciences at USC, DJ got me in touch with someone he knows who is interested in public health, Daniel Bachhuber.

Daniel and his friend Isaac Holeman had collaborated on trying to merge FrontlineSMS, (a software program that allows for bulk text messages, automated responses, grouping of cell phone numbers and many other features,) with OpenMRS, (the organization Partner In Health’s electronic medical records system). At 2008’s Netsquared conference, the two were finalists with this merger proposal. MobilizeMRS was its name, but it would soon become a larger organization called FrontlineSMS: Medic, thanks to further partnering with some Stanford University students.

Because I was trying to find an idea that could be implemented in Hubli, Karnataka, India, where I knew there was little in the way of electronic medical records infrastructure, Daniel and Isaac suggested I aim for a simpler technology than their MobilizeMRS. They got me in touch with Josh Nesbit, a Stanford undergraduate who had successfully implemented a pilot project called Mobiles in Malawi. He first used FrontlineSMS without the more complex link to an electronic medical records system, which can be overly complicated technology for rural populations who have little-to-no knowledge of computers and or mobile phones.
I was eager to bring this project to the table and very early on got great feedback about its potential- both for impact and adaptation to India. After applying for the Global Impact Program as individuals in January 2009, there began a long process of project development, multiple proposal drafting sessions and eventually selection and rejection of projects. This was done by members of the Deshpande Foundation, which is the source of funding for the Global Impact projects.

By consulting carefully with the ever-so-helpful FrontlineSMS: Medic team (Isaac, Josh, Lucky and Nadim- see their web site), I spearheaded the project proposal of team SMS. After it became one of the approved projects I soon welcomed Jonathan Goldford and Dan Greenberg to the team- two amazing additions, both Business majors who could bring a fresh and different perspective from my own (particularly in the area of organization). I had been working with Jon all semester in my first and only college business class, Global Strategy, and knew him to be a natural-born leader with monk-like patience, a seemingly inexhaustible work ethic and a soothing willingness to lend a hand to teammates in need of help. After beginning to get to know Dan I was initially blown away by how much he had already pursued social development- co-founding a chapter of Net Impact at USC. I always left our conversations and on-campus speaker events where we ran into each other, mind abuzz with exciting thoughts and new possibilities.

After some re-working of the Global Impact team rosters for the three projects, the SMS team was lucky enough to welcome Tapasya Desai. In the initial stages of the project, even before it was definite that she would be a member of the team, she was always the most attentive and quick to respond to my project proposal logistical emails and her knowledge of Hindi (which she will self-deprecatingly claim to be minimal) seemed, and now has undeniably PROVEN, to be a powerful asset. The language and her cultural understanding of Indian people has allowed us to approach many a person with warmth and a bond that can only be had through understanding of another person’s language and thoughts. I knew Tapasya and I would be able to chat about both saving the world (given the nature of the program) and the lighter side of life (evidenced by her extremely helpful recommendations for my spring break trip to Miami in March)!

With our team fully formed, we had only to search more actively for a partner NGO. This would be a complicated process for various reasons. As Dan pointed out in his last post, there were many things that would change once we finally landed in Hubli. Our team will write a fully detailed account of our project’s full process once we have made more progress. Please stay tuned.

~Lena