“Ashoka’s Changemakers, in partnership with the Robert Wood Johnson Foundation, is launching the “Rethinking Mental Health: Improving Community Wellbeing” competition in order to explore innovations that allow individuals, families, communities, and society to move past narrow perceptions of mental health and expand our understanding and collective involvement in finding solutions. The winners of this Changemakers collaborative competition will be those entries that best meet the following criteria”:

• Innovation: This is the knock-out test. The entrant must describe a systematic and/or disruptive innovation in the field of mental health. The innovation should be a unique model of change, demonstrating a substantial difference from other initiatives in the field and ready for large-scale expansion.
• Social Impact: It is important that the innovation provides a system-changing solution toward improving individual and community wellbeing. The entry must demonstrate impact on the target population it addresses, either a specific underserved community or the society at large. Some innovations will have proven success at a small level, while others will have grown to engage millions of people. Regardless of the level of demonstrated impact, it is important that the innovation has a potential for application globally. This will be judged by considering the innovation’s potential for scale and replication, in addition to the entrant’s ability to formulate a clear “road map” to reaching larger goals.
• Sustainability: For an innovation to be truly effective it must have a long-term plan for securing financial backing and community support. Entries should describe not only how they are currently financing their work, but also how they plan to finance their work in the future. The most successful entrants go beyond discussing whether or not they will charge for services and describe a business plan. They should also demonstrate that they have strong partnerships and support networks to address an ongoing need, and to aid in scalability and the maintenance of a clear financial strategy.

Mayo Clinic, Global Health and Design Thinking. You might be wondering what those three terms have to do with each together. This is my partial recap on time spent at the Mayo Clinic this past week where I saw one potential vision of what the future of healthcare might look like. It was a great privellege to hang out at the Mayo Clinic for what was the best conference I have attended in a long long time or maybe ever (Amy Tenderich at Diabetes Mine also has a recap that I encourage you to read). The Mayo Center for Innovation hosted a TED style event – Transform, a collaborative symposium on innovations in health care experience and delivery, all the videos are online (highly recommended viewing). It is going to take me a few months to digest what happened there and wrap my mind around everything I heard. There were over 430 people from 23 states, 7 countries and over 1,350 tweets. The caliber and just genuine niceness of every person I interacted with was on some other level, the conversations were rich, deep and thoughtful. The conference organizers *created an open purposeful environment* that led to an incredible experience. The folks at Mayo certainly shaped and designed a great space to achieve the symposium goals (this all reminded me of the Winston Churchill quote – “We shape our buildings and afterwards, our buildings shape us”).  Let me stop before you think I have joined a cult. The direct connection to global health here – it was discussed by keynote speakers and my first tweet from Mayo was “this place reminds me of Aravind (Aravind Eye Care System). Jaspal, Mahad and I have written several articles and cases studies on Aravind and I continue to believe it is a premiere model for innovation and care delivery. More on this in a bit.

The Global Health Convergence: “Design Thinking” and Innovation
There were many things that made this event great, however, in terms of extending your horizons and making you think, one of the most refreshing things was to see some convergence of disciplines and people from a variety of backgrounds. This is very hard to do and cannot be underrated. We all live in a sea of fragmentation,  in systems, in professions and fragmentation in how we solve problems. This is even reflected on a micro level – look at the mainstream peer reviewed journals in healthcare where you see severe fragmentation amongst the physician, nursing and pharmacy focused journals (some of this is for good reasons and some of it’s not). This conference was in part about ditching that fragmentation and about a convergence of ideas, people and relationships working collaboratively. In addition to innovative projects, new models of delivering care and how the process of innovation can be conceptualized, managed, and enabled was discussed. Much of this was encompassed under the umbrella of Design Thinking (innovating and problem solving using various methods). Tim Brown, CEO of IDEO, was a headliner on this front and re-emphasized a call for design to big, an ethic of design for social impact/change, which Jaspal and I have covered on this blog before (see our previous post – 8 Links for Design and Global Health).

If you were too look at the methods of design thinking you would see an amalgamation and convergence of mostly existing methods from a variety of disciplines (from engineering to ethnography to epidemiology to psychology to health services research to name a few examples). As Tim Brown said in his talk: “Design thinking begins with integrative thinking which is the ability to hold opposing constraints and opposing ideas and from those create  new solutions…this means balancing societal needs (desirability) with what’s possible (feasibility) and what’s sustainable (viability)“. When Tim Brown said “Design should not be left in the hand of designers” he hit the nail on the head – design thinking can be incorporated by non-”designers” to help innovate and solve problems. What we do has to be a participatory, collaborative effort. Tim Brown wrote more about this participatory perspective (How to Design a Participatory System in a post crisis economy world). There are many critically important reasons why this is a key factor, one of which goes back to Paulo Freirean educational tenets – people who participate in their own education, become engaged in the transformation of their own world. The other reason is because even though as brilliant as Tim Brown is, (and all the people working at organizations like his) he doesn’t have all the answers, or even the correct ones (read his other piece at FastCompany on HSAs where his point is highly debatable about the solution and at best has over simplified the problem).

The bottom line that I took away is that we need more of a participatory system, we should be open to new ways of approaching problems (“design thinking”) and we can provide some structure to the process of innovation. Besides design thinking the other major theme I want to point to is global health – as I said above in the keynote presentations global health made an apperance. Both Clay Christensen and Tim Brown mentioned the Aravind Eye Care System and Jaspal spoke entirely about global health. We have said on this blog before that there are many lessons that can be learned from outside our system where innovation is taking place due to extreme necessity, it’s not a choice (a lot of this is taking place over the web and with mHealth – mobile phones for health). In Global Health, there are hundreds, maybe thousands of innovative experiments going on using a wide area of technology (devices, drugs, the web, mobile phones, etc.), however, how we track these experiments, talk about failure, and share what has been learned seems to be highly inefficient and lacking.  We have covered a lot of this ground over the past three years, the easiest summary of examples can be found in this post:

42 “Extremely affordable” Innovations in Global Health

Clay C, Tim B, and Jaspal all pointed to global health as a place we can learn from. While there are some serious limitations, there is a ton to learn from the use of mobile phones in developing countries and how that might apply here – because overseas usage of phones is far beyond what is being done in the US. The other area to keep an eye on is chronic diseases. In some places, there is going to be an explosion of chronic conditions and new models will have to be devised to handle that tidal wave. I would love to see Amy Tenderich and her community do a brainstorming session on design for diabetes in developing countries. On this front see two previous posts:

1. Reverse South to North innovation – Borrowing innovation: health services, financial services, and clean tech
2. A massive wave of chronic disease in India and China

Let me leave you on a note of caution, a “design thinking” approach (remember using existing methods) can offer some powerful alternatives. However, there can also be something seductive about design thinking and a rapid approach (we’ve cautioned this on the graphics/visual side before). If you fall into that seduction, then this is just a fad for you, it’s on us to be rigorous, thoughtful and corrective when need be:

“The myth of innovation is that brilliant ideas leap fully formed from the minds of geniuses. The reality is that most innovations come from a process of rigorous examination through which great ideas are identified and developed before being realized as new offerings and capabilities.” IDEO website.

I have many more thoughts on this, if I get the time I’ll jot down a few more notes and quotes from the conference, in the meantime, it is well worth watching the videos from Transform.

My PictureRx is designed for the domestic US market, but I thought I would post it on the off chance that it might stir up some ideas for situations in low resource settings. Not clear if they have gone mobile with this. While there are a slew of SMS pill reminders (first used in a widespread way in the “South”) it is important to think about this in development context due to the coming wave of chronic diseases – how well do SMS only medication remdiners work for people with co-morbidities and complex drug regimines? Also important to note – this is just one type of tool among many, and doesn’t seem like it helps with remembering whether you took your pill or not (have you ever looked at your watch for the time and then forgotten the time 10 mintues later?). The design looks slick and you can sign up for email reminders, however I am not sure what the efficacy is. Other issue to keep in mind with SMS reminders or something like this – while you can improve pill popping rates (adherence), there are many situations where people don’t want to take their meds (side effects or getting plan fed up with the polypharmacy).

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• Text Message Reminders help Teen Transplant Patients (textually.org)

1. China is now Coke’s third largest single market, link [think about this in the context of obesity and chronic diseases in Asia]

2. Ensuring better air quality for the Asian Games, link

3. Vigilante public health supported by the public, link

This last story really caught my attention:
A retired teacher has become an Internet sensation after he lobbed dozens of bricks at cars that ran a red light in Lanzhou, Gansu province. “I just want to catch people’s attention and tell the drivers to think of pedestrians,” the 74-year-old man said. The elderly man, has attracted a lot of attention online, with nearly 400,000 netizens responding to a Sina.com poll. Nearly 80 percent said they supported his actions. A netizen called Biyuding20008 said too many drivers do not follow traffic rules like stopping at red lights and not talking on phones while driving. The man became a crusader for road safety after a female pedestrian was killed in his community last year. “Even when the light is green, drivers just ignore it and don’t slow down for pedestrians,” the man told the paper. In order to punish drivers and draw attention to poor driving habits, the man planned to throw bricks at all cars that ran red lights…

Traffic and road accidents are a major problem in Asia and will be one of the top 5 “disease categories” by 2020. In my first 24 hours I got a glimpse into what China is hurtling towards. In conjunction with the failed climate change talks at the G8, the stakes are huge and China is also dealing with cultural transformation, demographic and employment/labor issues, all happening at warp speed. As the United States is going through a major reset and downturn and continues to buckle under the weight of special interest groups from the financial, food/beverage (from soda to tobacco) and health industries I wonder what lessons China will import from a failed health system in the US as it undergoes it’s own health reform.  Maybe they will need more vigilante public health to make sure they move in the right direction.

Other related posts:

The Power of Image in Public Health Education: China 1930-2004
A Massive Wave of Chronic Disease in China and India
Beijing Olympic Cause Marketing & Global Health Ads
China and Global Health
China is Choking
Trends: Global Pharmaceutical Manufacturing and Investment

A Massive Wave of Chronic Disease in China and India, link

The 88 Worst Fast Food Items, link

Scientific American on Food, Fat and Famine, link

The above two headlines on global health funding flows and allocation caught my attention. The original study was published in PLoS Medicine. The article has some great figures (some of which I have reproduced below). A few things immediately stick out – the amount concentrated on HIV/AIDS, TB and malaria is astounding. Second the US is providing 70% of the funding and on the surface one could argue that other countries really could be pitching in more. On that note, the Gates Foundation by itself is out funding the European Commission almost 4 to 1 – if that isn’t embarrassing I don’t know what is. Finally, the US Department of Defense is high on the list (surpassing USAID). Interesting stuff:

“HIV/AIDS, tuberculosis and malaria initiatives accounted for about 80% of the $2.5 billion that was spent on research and drug development for developing countries in 2007… However, pneumonia and diarrheal illness, which are two major causes of mortality in developing countries, received less than 6% of funding.”

Original Sources:

• PLoS Medicine – Neglected Disease Research and Development: How Much Are We Really Spending? Link
• WHO Top 10 Causes of Death, Link
  

Three Observations in Arab Healthcare Delivery

I attended the 34^th annual Arab Health Congress in Dubai last week. This is the largest regional conference on healthcare. The event was massive: it drew more than 50,000 visitors and 2,300 exhibitors which span all facets of healthcare including care delivery, technology, consulting, staffing. According to the medical director in Abu Dhabi’s Sheikh Khalifa Medical City, ‘Our institution looks forward every year to Arab Health as a means of reviewing the latest technology; networking with suppliers and vendors and to update medical knowledge. The increased participation and attendance at Arab Health is of value to all of us in the healthcare field.’ Here are some observations on the delivery of healthcare in this part of the world:

Economic Downturn Putting Projects on Hold

The global financial meltdown has not spared the Middle East and the UAE in particular. There are many sites that are empty pits with cranes standing idle. Hospitals have put on ice new expansion plans. Overall, it is estimated that 8% of the labor force in Dubai has left the country in the last four months due to the worsening economic climate. I heard a couple of people talk about the thousands of cars that were left abandoned at the Dubai airport as people could not pay their loans and thought it best to flee the country. Up until last year, healthcare expenditures in the region were growing 16% per year and exceeding $74B.

The silver lining here is that global steel prices are down 75% and smaller construction projects at well-capitalized institutions can for the first time gain traction. A notable exception to the economic dip is Qatar. According to ArabianBusiness.com, Qatar’s economy (http://www.arabianbusiness.com/541046-qatar-economy-could-grow-by-10-in-2009) could grow 10% in 2009 as it expands exports of liquefied natural gas, making it the world’s fastest growing economy.

Thirst for World-class Standard of Healthcare

There is a strong desire in the Gulf to catch up to the healthcare levels of the industrialized world. Until just a few years ago, the only way to bridge the gap between what national populations desired and what was offered in their native countries, was to open the doors (wide open) to medical tourism. The UAE reportedly spent over $2B per year to ship its citizens to foreign countries for medical treatment. Not only were these expenditures unsustainable, but they put these countries at a competitive disadvantage for recruiting highly skilled expatriates. The only way to turn down the medical tourism spigot was to invest locally in building healthcare expertise. Due to poor perceived quality in local healthcare, stymied access to care, and perverse financial incentives to go abroad for care, medical tourism is still a powerful force.

Enter Multinational Healthcare Corporations

The landscape for international healthcare providers with business in the Middle East is becoming increasing crowded with the major players hailing from the US, Europe, and Canada. There seem to a few dominant models:

a. Market Destination Hospital: A number of institutions have outposts in the Middle East that they use to run clinics and make the necessary arrangements to funnel patients to the flagship entities. Mayo, Washington Hospital Center, University of Chicago follow this model. The Great Ormand Street Hospital in London sends in a rotational team of pediatric specialists to run clinics close to the patients.

b. Secure Management Contract: This is where the cash is. Running a tertiary hospital in the UAE can yield $6M per annum. The big players in this sector include Cleveland Clinic—which runs Sheikh Khalifa Medical City and will run the new Cleveland Clinic Abu Dhabi when it finishes in a few years. Johns Hopkins International has three affiliate hospitals in the UAE and a hospital in Beirut. UPMC runs the gamut of managing whole hospitals to managing individual departments like the emergency room. The Methodist has teamed up with property development company Emaar to create an outpatient clinic which they will manage—the Burj Medical Centre. Emaar has aggressive plans to expand clinics and hospitals throughout the Middle East and North Africa.

c. Joint Venture: South African Mediclinic obtained ownership share of Emirates Healthcare in 2007 for $53M. With two hospitals and three clinics in the pipeline, they are the largest private provider of healthcare in Dubai. Mediclinic derives nearly half of its profits from overseas ventures (in the Middle East and beyond).

While it is quite exciting to see all this development in healthcare, everyone agrees that the only way to have real, sustainable progress in region is to build an army of indigenous healthcare workers. Unfortunately, the curse of petrodollars is that it leaves little incentive for nationals to aspire to become nurses and doctors, let alone outstanding clinical managers. In the meantime, India and the Philippines serve as the golden geese.

For better or worse we are already far down the path of celebrity endorsed causes (what impact this has, I really don’t know, but it certainly commands some attention in a world with lots of noise and information overload). We have Bono, Bill Gates, and Bill Clinton – all rockstars for global health. Even NextBillion is advocating for rockstars in public health, which I do agree with. Sanjay Gupta is extremely smart and talented and can be a celebrity for public health on a national scale. And actually much more than a rockstar, public health in this country and globally needs an ambassador, a champion and an activist. This pick is good for both domestic and global health, and the two have never been so intertwined (not just with the migration of infectious diseases across borders but also with the explosion in chronic disease (and see here Jan 2009)  in developing countries and issues like brain drain). You would have someone who has appeal beyond the experts and policy wonks, he has strong credibility with the American public. As such, this is a great media strategy by the Obama team – they have found someone who is well known, a media professional (and as some criticize – a propaganda machine), and can deliver complex health policy messages.

As with any candidate there are drawbacks and deficiencies, with Gupta, these will all come out in due time. I understand that some in public health circles and others will consider this pick to be more style than substance, but my main point is that is time for us to think creatively beyond our traditional notions and perhaps take a risk with someone who doesn’t have a strong public health background, but who has the potential to have a major positive impact.  Gupta is someone who can link both local and global health causes together and that is rare and signficant skill. The envirionmental movement over the last decade has made tremendous strides in melting the division and lines between local and global into something that can be grasped at all levels and into something where people understand the connection. Granted health is a very different animal, but as a community and movement we are light years behind the environmental folks – perhaps Gupta helps to push this in another way.

Other sources:

- Krugman on the Trouble with Sanjay Gupta, link
- See Abel and Jake over at Science Blogs on their differing views
- WSJ health blog on Gupta, link
- Read the comments over at Daily Kos, link
- Huff Post on Gupta, link
- Questions about Gupta at KevinMD, link

“with regard to ExxonMobil’s commercial on Malaria during prime time, when over 1 Billion people were watching, this might have been the largest audience ever for a global health ad.”

I realized after I said this that I probably made a major miscalculation. The NBC channel broadcast I have been watching is only produced for an American audience. The top estimates I have seen for viewership at a given time hit 66 million people. So while Exxon may have had their ad broadcast across countries and major national networks, it is likely that somewhere between tens and hundreds of millions of people saw their commercial – which is still an impressive number. Thanks to Responsible China I found the youtube version of this ad, which is below. In addition I have also seen GE’s portable re-designed low cost EKG machine advertised several times as well. Despite what you may think about these companies it is better than nothing to see MNC’s promoting social causes. We blogged about the EKG machine previously and the commercial is the first one below, followed by the malaria ad. For another check, definitely check out ResponsibleChina.

[youtube=http://www.youtube.com/watch?v=yB47wx-b6sY]

[youtube=http://www.youtube.com/watch?v=s7qVlbG1i7A]