Chaos Muppet Strategic Planning

A Guide for Plotting the Rest of Your Life, Terrifying Your Neighbors

 

I’ve spent the past few months in this exceptionally weird, expansive state of nondecision. There’s a scene in the last episode of the West Wing – someone’s trying to decide what to do after the administration ends – and the resident curmudgeon replies: “You’re a woman with a lot of options and you’re acting like the world is backing you into a corner. Maybe you should stop bouncing, pick something.” Ugh. Exactly. I’ve watched it a billion times and yet still couldn’t manage to pick a thing. (For what it’s worth, the way I feel about jobs has helped me understand how the rest of you feel about Tinder.)

Talking and kvetching about, I’ve gotten the sense that this is everything-is-possible paralysis runs particularly rampant in early-career global health and development circles for a few reasons:

  1. People tend to be drawn to this realm out of a compulsion to address particular problems, but when it comes to translating that into a functional career, there are fifty different ways to work on the same thing. (You come out of an internship in undergrad struck by the problem of antimicrobial resistance, say – but do you work on drug pricing? Pharmaceutical incentives? Behavioral research? Medical research? An intervention-based startup to improve compliance? Russian prison reform?)
  2. This space is also overwhelmingly interdisciplinary (epidemiology bleeds into biosecurity which bleeds into soft power and regional dynamics, which bleed into U.S. foreign policy…and that’s just my weird corner). In my experience and perhaps in contrast to other arenas, this actually gets worse with research-oriented graduate education.
  3. There’s also the problem of a hiring bubble: students emerge from MPHs & similar programs with concrete experience and hard research skills, feeling capable of doing a lot but mismatched to market dynamics or otherwise priced out (expected to intern after a master’s, etc).

I’ve also been getting a lot of emails asking for general career advice lately (which I am still totally happy to answer, eventually). But when wait-I-need-a-job season started in full force around February I had no idea what I was doing & so felt like the falsest prophet. Once I figured that out, the process I came up with was so clarifying that I thought a generic guide would be a useful standing resource.

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Buckle up.

Continue reading “Chaos Muppet Strategic Planning”

Chaos Muppet Strategic Planning

Valar Morghulis

Introduction:
Game of Thrones, for those of you who are not familiar (I am really not; see disclaimer), is famous for high mortality rates that make viewers and readers very angry. As a global health graduate student (with a lot of free time at the moment…) I became interested in figuring out precisely how bloody this universe was, whether deaths varied by gender and status/occupation/affiliation, and how mortality in Westeros compares to mortality in low- and middle-income countries. The professor for a course I’m TAing in a few weeks also mentioned that he wanted an assignment on life tables, so, you know, I figured I should learn what they are.

No character names are used in this blog post, but I guess there might be spoilers if you can back-calculate in your head. Continue reading “Valar Morghulis”

Valar Morghulis

Burdens of Disease.

People have been asking me lately, as I’ve bounced from place to place, why I find the Middle East an interesting place to pursue global health work. There are about fifty different answers to this, but in short: I think inequality within countries makes for more challenging distribution of resources than inequality between countries, I’m interested in how healthcare can be used as a political tool, and I expect the challenges much of the region faces now to be similar to those some areas of Africa will face in twenty-thirty years. But the easiest explanation is quick and visual.

Continue reading “Burdens of Disease.”

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Amman: Round Two

I’m headed back to Jordan this summer for thesis research, fieldwork, and (of course) weekend canyoneering. The original plan was Beirut – still angling to make it back & forth a few times. Here are a few things I’m going to work on while gallivanting about the Levant. All advice, criticism, and insight is more than welcome!

1. Gather some hard data on how immunization rates change during Ramadan.

I’ve been tracking patients that miss their immunizations for about seven months now. We started *just* before Ramadan last year, and noticed a pretty substantial increase in the number of missed appointments during that time. This is probably not surprising to anyone, but it’s also completely unstudied. Delaying immunization by a week or two isn’t a huge problem in an area with decent herd immunity, but waiting a full month before maybe forgetting about it, when migrants and streaming in and out from a warzone where hospitals are being bombed, when polio strains are blooming across the border, when we’ve seen unprecedented outbreaks of infectious disease along Syria’s border with Turkey? That’s not a good idea.

My hunch is that general fatigue and a mismatch between maternal waking hours and clinic hours might be the major inhibitors, but I’m open to other ideas (someone just told me some people view vaccination as breaking fast). No moms want to wait in line for hours in the early morning after preparing food all night. Nobody wants to do anything at 3 p.m. after nine hours without food or water. I barely drag myself to 8 am classes on normal days and definitely cannot without scary volumes of espresso, so I feel like these things aren’t unreasonable. One specific goal is to channel these findings into specific policy recommendations on clinic hours, which could be a good work-around.

2. Expand UNRWA’s mobile health capacity. We’ll be issuing immunization prompts to more clinics – hopefully some outside of Jordan, and some catering to Palestinian-Syrian double-refugees! – and gathering some hard data on effectiveness and patient satisfaction. Beyond that? The specifics are still up in the air. One promising suggestion from last summer involved sending reminders on basic aspects of diabetes management to adult patients. I’m not a huge fan of basic mobile health initiatives like this (engineers are technology snobs), but I do think they can be especially useful for patients with limited mobility. Gaza New Camp, in Jerash, provides a good (well, awful) example. The ’67 refugees who live in the camp were not afforded Jordanian citizenship, so they can’t obtain licenses or buy cars; if they bought motorcycles instead, however, they’d be short-changing the Jordanian economy by investing in a cheaper mode of transportation, so they’re also not allowed to buy motorcycles (cue eyeroll). So, if you live there, and your diabetes symptoms progress beyond anything you can manage, good luck getting to your regular dialysis treatments.

Of course, it’s not a problem if for Jordanians who reside in Abdoun mansions – take either of your Porsches down to King Hussein. But that kind of extreme disparity is what allows global health issues in the Middle East to fly under the radar: everything averages out to Middle Income Yellow (new Crayola shade?) and funding is directed elsewhere. Bigger rant on this later.

3. Health care as a bargaining chip. This is an iffy one, perhaps best illustrated by Hezbollah. They provide medical care that drastically undercuts the going rate on Lebanon’s private market, and care is FREE for Hezbollah party members. If you’re poor and sick and on the fence, is that opportunity enough to sway your political stance? There’s rumor of similar models being tested by different extremist groups in Mali, and I’m worried that this might be a growing phenomenon as AQIM spreads southward throughout and across the Sahel to sicker and more impoverished lands.

To be fair, one could argue that USAID does the same thing, “From the American People” emblems and all – maybe that would make a nice proxy study. I’m not sure exactly of how to pursue this line of investigation, but I think it’s really important and I’m surprised it isn’t getting more attention. Tentatively, I’d like to head up to Zaatari, where UNRWA is trying to deal with lots of pharmaceutical theft & redistribution, to see if there are any grander motivations aside from making a buck on the UN’s dime. Maybe I’ll gather up the gumption for more casual interviews in Beirut. More broadly, if there is any real political shift that comes from this discounted care, I’d like to see it incorporated as a very low-cost national security strategy. The US is good at fighting fire with bigger fires, but fighting knockoff pharmaceuticals and pandering with effective, strategic, and heartfelt health investments seems like a much better deal to me.

Amman: Round Two

Defining Success in Appropriate Medical Design

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I tweeted this during a lecture from the wonderful Dr. Bob Malkin, who founded Engineering World Health and does some great research identifying actual barriers to use of medical equipment abroad (disclaimer: I may have taken that from his slides, I don’t remember). I’ve worked on a neonatal device that won some big design competitions, so this resonated strongly with me. It got a little bit of traction, so I’m guessing it struck a chord with a lot of other people in this niche, too.

Of his selection of the top 10 or so neonatal devices deliberately designed for resource-poor settings (hospitals with irregular electricity, for example, or clinics that are short-staffed), zero have African manufacturers or distributors. Zero have reached one million treated patients. All won major design competitions. These goals should not be outlandish – try getting VC funding for an app in the Valley without a million projected customers – but it’s been at least three or four years since this type of focused design for hospitals abroad became a Big Thing in university circles, and achieving those goals on this timeline would frankly be small potatoes in the private sector.

If you sit in on any business school competition, you’ll find a Saving Babies Device among the winners. A quick google search will come up with tens of biomedical competitions either specifically for low-resource settings or with a category for the arena. Don’t get me wrong, I’m glad to see the attention – even Y-Combinator opened to nonprofits recently*. But I think they tend to capitalize on the feel-good factor rather than on what can actually get to market.

It’s worth noting that I think the two companies that have gotten the closest to these goals (Embrace and Brilliance) do mimic private-sector distribution channels by selling equipment rather than donating and maintaining strong R&D teams. The less successful products either linger in university tech transfer offices or get shuttled into nonprofit models, where funding is frankly not sufficient to support health research. In fact, overhead costs for most life science companies can reach 50% – far beyond what most donors are willing to stomach. The perception of low overhead costs as the hallmark of a worthy philanthropic venture is beginning to change, but there’s no denying that the type of people capable of designing neat medical equipment have particular skills with a much higher market value than those of other nonprofit employees, and that lab costs are high for quality products. This shouldn’t even out anytime soon.

So, potential next steps:

1) Design competitions are nice but they need to come with more solid backing. Make prize money contingent upon licensing or formation of an LLC, or deliver it in stages based upon patients reached.

2) Focus more on designing efficient back-end systems that support local manufacturing (another gem suggestion from Dr. Malkin – mass paint systems! None in Afria). “Industrial engineering for the developing world” doesn’t sound sexy, but there would be a WHOLE lot of money there.

3) Continue the shift towards low-level prizes contingent upon iteration and scaling (the DIV model**, basically). I’m all for designers patting themselves on the back, but it’s most rewarding when in service of work milestones, anyway.

4) Do. Not. Donate. Devices. Don’t do it. I don’t care who you are or how much money you have or how good it makes you feel or how right you think it is. Donate money to the hospitals, sure, but don’t undermine the economic chain that leads to the creation of better technologies within this sphere.

*I think Watsi is really dumb though, but that’s a post for another time.

**Disclaimer, I intern for them

Defining Success in Appropriate Medical Design

Infants, Infection, and Insurgency: Disease Burden in Afghanistan

For a general Western audience, mention of Afghanistan may bring to mind several narratives: domestic implications of endless war, wariness of radical Islam, images of burning poppy fields supplying the international drug trade. While these observations are grounded in some degree of fact, they largely reflect an extraordinarily poor society with significant barriers to development just beginning to rebuild. To put this in perspective: the average Afghan* woman will live to 52 years and will bear six or more children. The average male will support his family on an annual income of $584 USD, and will not see the age 50.

Of course, this sort of extreme poverty extends to health access. Of the different population- and disability-adjusted life year burdens measured by the Institute on Health Metrics and Evaluation, Afghanistan comes dead last – behind all other countries – in 19 of 50 categories.

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Relative comparison of the 15 countries with the highest disease burdens. That red ain’t a good thing (source: IHME).

At nearly 120 deaths per 1,000 live births, Afghanistan’s infant mortality rate is higher than that of any other country; in its especially remote regions, such as the Wakhan Corridor, an estimated 50% of children die before reaching the age of five. 34 years of constant war have wreaked havoc on health systems, skepticized a populace, and left mortality and morbidity burdens frozen in time, reflective of another era. Continue reading “Infants, Infection, and Insurgency: Disease Burden in Afghanistan”

Infants, Infection, and Insurgency: Disease Burden in Afghanistan

Let’s Talk About Intellectual Property and Global Health

There’s something unique about building and creating in a humanitarian field. Your goal, on one hand, is to work yourself out of a job: you want your inventions to be so contextually appropriate that they remain feasible, so culturally apt that they are used correctly, and so accurate that the results are akin to those in a New York hospital. Your achieve success when you eliminate the health problem you were attempting to stem.

On the other hand, when you design for lower-resource settings you are designing for emerging markets. You hope that the health benefits of your invention will contribute to a cycle of productivity: of lower disease incidence, of more school days for children that would otherwise be ill, and ultimately of economic growth and increased earnings. You are building your work into the fundamentals of a nascent health system, with the hope that your design will flourish within this new system and remain relevant. Stemming a health problem is not the end-all; it is a stepping stone on the way to sustaining access to continued care.

I’m working at a foundation right now, and the purpose of IP protection for nonprofits and social ventures comes up for debate on what I would hazard is a weekly basis. While both sides propose that such organizations should want their efforts to result in the maximum amount of social good, one argues that the best way to achieve this is to share productive innovations openly – that overriding the egotistical human desire for ownership would result in greater total implementation, and a greater total number of lives saved.

In other words: if you truly want to help people, how dare you attempt to make a career for yourself in this field rather than voluntarily giving away your efforts. I find the degree of guilt-tripping that this mindset perpetuates very short-sighted. “Don’t you want your efforts to go to saving babies/reducing disease rates/increasing crop yields?” Well, yes, of course we do – if we didn’t, we would be working at for-profit engineering firms. But social ventures cannot perpetuate their ability to do good*, and to create new solutions, without receiving living wages and a financial safety net with which to invest in further research and design.

My stance is that this method of operation drives high-talent individuals away from the social sector and forces said ventures to remain beholden to donors.  Being beholden to shareholders (by licensing bottom-of-the-pyramid designs to for-profit companies) is equally limiting: it delays the urgent business of providing such technologies to the locations most in need, rather than middle-income markets.

I maintain that the best way to maintain creators within this space is to provide them with a sense of ownership, and that maintaining high-quality creators is critical to building relationships with end users and clinical partners. In order to accomplish these things, creators need to out-perform other organizations when competing for donor funds or applying for grants. And in order to do this, they need to be able to protect their intellectual capital.

So, where do we go from here?

Peter Haas of the Appropriate Infrastructure Development Group mirrors my thoughts exactly:

“Sorry to break it to you, but this field is one largely of boutique players and very insular boutique operations in large companies. There aren’t many jobs out there to be had, and you need to look hard to find the ones that come up every once and a while. Most people in this field make their own jobs as entrepreneurs and consultants.”

Aside from the opportunities pointed out by Mr. Haas, it’s worth noting that a (relatively) tremendous amount of funding for global health research is channeled through universities. Interest in the field is growing for students of all disciplines, and it’s also worth noting that many low-cost health technologies are prototyped equally cheaply by students.

Stanford provides a particularly successful model for developing new opportunities, in part by honing their openness to student entrepreneurship in the for-profit tech sector. D-Rev, Embrace, and Medic Mobile all have roots here. That is not a coincidence. Stanford’s willingness to allow students to pursue their own inventions, which are unlikely to turn a profit if licensed, has resulted in a transformational impact: the products are life-saving, yes, but more substantial are the hardware and software engineers, the business students and fellows, the executive directors who are now freely and actively working to create more life-saving interventions.

But few seem to have followed suit. Diagnostics for All came out of Harvard, which kindly licensed patterned paper diagnostics from the Whitesides Group to the nonprofit (and I would hazard that Whitesides’ influence played no small role in this decision). But licensing fees are often out of reach of burgeoning nonprofits, and even if that were not the case, I understand that universities would be hesitant to relinquish potential profits. It makes more financial sense for these institutions to keep BoP technologies in-house, where they can be used to bring in grants (see Jhpiego at Johns Hopkins) and where tenured professors can pursue this type of engineering-for-change without worrying about financial security or market viability.

This model is not useless, and it does lead to the continued production of low-cost health technologies, often at the prototype scale. But it is also not transformational. For broader impact, universities need to leave the door open for students to pursue their inventions to market. New product-centric social ventures focused on health design for low-resource settings will broaden the scope of new health interventions, even the financial playing field for these organizations with higher-than-standard overhead, and provide an outlet for students to pursue this field instead of other potentially lucrative options. To summarize that mouthful of a sentence: this combination is what we should aspire to if we want to sustain this field beyond its boutique origins.

*For more thoughts on the application of this line of thinking to the broader nonprofit sector, see Dan Pallotta’s wonderful TED talk from this year.

Let’s Talk About Intellectual Property and Global Health