Design Research for Global Health

Mongolian Babel fish?

Yesterday's New York Times article by Miguel Helft, Google’s Computing Power Refines Translation Tool, presented Google's strategy for automated, online language translation. Google wins because they have both the data and the horsepower to make statistical approaches to automated translation effective. Right now, Google Translate accommodates 52 languages. And that means any combination of language pairs from that 52, so for example you can translate Estonian into Vietnamese. Not perfect, but it's much better than where we were even a few years ago. Here's some text from kaunis.ee translated from Estonian to Vietnamese to English using Google Translate:

• Estonian: Kõik me soovime olla kaunid, olla ilusad nii sisemiselt kui väliselt. Nii sisemine kui väline ilu on mõlemad ühtmoodi olulised ning mõlema eest tuleb hoolitseda. Lõhn, jumestus ja riietus moodustavad isikupärase stiili, sinu välise ilu. Sinu ilusse soovime anda omapoolse panuse ka meie, olles abiks lemmiklõhnade ja kosmeetikatoodete soetamisel.
• Vietnamese: Tất cả chúng tôi muốn được đẹp, phải đẹp cả trong nội bộ và bên ngoài. Cả hai vẻ đẹp bên trong và bên ngoài là cả hai đều quan trọng và cần cả hai để chăm sóc. Mùi, trang điểm và ăn mặc đến phong cách cá nhân, vẻ đẹp bên ngoài của bạn. Vẻ đẹp của bạn muốn đóng góp cho chúng tôi cũng đang được và giúp lemmiklõhnade mua mỹ phẩm.
• English: We all want to be beautiful, be beautiful both internally and externally. Both beautiful inside and outside is both important and both need to care. Smell, makeup and dress to personal style, the beauty outside of you. The beauty of you want to contribute to our well being and help lemmiklohnade buy cosmetics.

To put that 52 number in perspective, the top 20 languages in the world account for 5.1 billion speakers, or roughly 75% of the world population (calculation from WolframAlpha). On the other hand, 94% of the world's languages are only spoken by 6% of the world's population. Communication and information access are important parts of translation, but so are cultural understanding and language preservation.

My interest in smaller languages is primarily because of my experience with Mongolian. There are only about six million speakers of the Mongolian macrolanguage, primarily found in Mongolia and Inner Mongolia. So it's not a tiny language and it's not in any imminent danger of disappearing. Still, automated translation tools would help communication and information access in both directions. For 99.91% of the world, sites like sites like Olloo.mn are incomprehensible. And for most Mongolians, sites like English Wikipedia are incomprehensible. (There is a Mongolian version of Wikipedia, with about 2% of the article count of English Wikipedia, but the quality generally isn't as good because of a lower number of active users.)

What was most interesting to me from the Times article was Google's plan for small languages covered in more detail on the Helft's blog this morning. They've created something called the Google Translator Toolkit. They are encouraging individuals to upload translations from other languages to their system, for example:

Mr. [Te Taka] Keegan uses a tool called the Google Translator Toolkit to upload Maori translations of English texts to Google. Others can then use those translations in their work, increasing the quantity and quality of Maori translations that are available, and creating incentives for children of Maori descent to learn the language.

What Google has lacked to date for smaller languages is data. Given enough participation, this may solve that problem for languages like Maori and Mongolian.

Mongolian of course suffers from another problem in practice, which is that it uses multiple character sets: Cyrillic, Mongolian script, and Mongolized Latin. This Mongolized Latin is especially prominent in chat and text messaging, and is not at all standardized. As I wrote in the language note for my dissertation "The word бөх (wrestler) can be romanized at least nine different ways (b{u,ø,o}{h,kh,x}), some resulting in ambiguity of meaning (e.g., “bull”, “all”, and if you’re not careful, “gum”)."

Yamli is apparently solving this problem for Arabic, by incorporating Arabizi-Arabic translation in its search. For now, one of the best Mongolian translation tools out there remains an "old-fashioned" one, Bolor Toli, an online Mongolian-English-German dictionary.

(The reference in the title is to this Babel fish.)

Reflecting on Mongolia in Cuba

Last month I was in La Habana, Cuba for the Global Forum for Health Research meeting Forum 2009, focused this year on the theme "Innovating for the Health of All".

It was a very international meeting, with participants from places as diverse as Suriname, Egypt, Zambia, Bangladesh, Brazil, Canada, Kenya, and China. Almost all of the foreign participants at the conference were coming to Cuba for the first time and everyone it seemed was struggling to make sense of the place. My primary reference point was Mongolia, because of the common political history that Cuba and Mongolia share - namely as preferred partners of the Soviet Union up until 1990. Since 1990, the two countries have responded to the withdrawal of Soviet support in spectacularly different ways. By the end of my short time in La Habana, I realized that my stay didn't help me understand Cuba as much as it helped me understand the pre-1990 Mongolian People's Republic, a place I only know indirectly - through oral histories, photos, music, and writing.

There are many apparent similarities between the present Republic of Cuba and MPR: concrete-heavy municipal architecture, strong pro-government advertising (e.g., Patria o Muerte), a complete lack of any other advertising, an emphasis on anniversaries (e.g., the 50th anniversary of the 1959 revolution), a government-dominated employment system, few cars on the road, multi-colored playgrounds - the same colors as are still found in Mongolian playgrounds, an emphasis on progress through technology, widespread covert surveillance, a National Circus located next to a National Children's Park, various state monopolies. The list really does go on, but it's probably best to just show a few photos.

Massive Russian embassy towering above the local surrounds (compare to the one in Ulaanbaatar):

 

Tribute to Karl Marx- this is the Teatro Karl Marx (how Mongolia did it in 1961):

 

Russian-made vehicles were all over the place. I learned the Mongolian-Cuban translations for Russian UAZ vehicles from a taxi driver - and he was tickled to learn the Mongolian nicknames: jaran yus = gua, furgon = guasavita. If you don't know what a jaran yus or a gua is, check out the first photo from last Sunday's New York Times piece about Tajikistan. There were also plenty of Kamaz trucks, Ladas, Skodas (Czech, not Russian), and a few Ij Planeta motorcycles. The photo below shows a Zil guch/30, locally known as a Zil ciento treinta/130 (here's a photo of a 30 in Mongolia):

 

Unfortunately, while Ulaanbaatar has a Cuban restaurant, La Habana doesn't have a Mongolian one. But there is mutual diplomatic representation:

 

I wrote about the meeting itself on the Global Health Ideas blog, in a series of six posts:

1. Innovation Focus on Cuba
2. South-South Cooperation & Scaling Social Entrepreneurship Models
3. Site Visit to Ramón Pando Ferrer Cuban Institute of Ophthalmology
4. Public-Private “Debate” Redux
5. Innovation for Remote Populations/mHealth
6. A Physical Therapist Headed to Tecate

Return to sender

Based on my recent work in Mongolia, I spent a good part of this year developing toolkits to help provincial health departments design improved systems for bagiin emch, rural health workers. (I still owe a blogpost about those toolkits.) In late July I shipped to colleagues at the Ministry of Health in Mongolia two boxes of these toolkits - 25 toolkits in total, one for each of the 21 Aimag Health Departments, and four for the Ministry. One box made it through while another was unexpectedly held up in customs. The Mongolian Customs officials demanded that duty be paid on the package.

Well, guess what arrived in the mail this week?

 

 

I shipped that package on 27-July-2009. From the paperwork it looks like Customs received it on 28-August-2009. I was expecting the customs issue to be resolved over there since it was just a box of documents, but of course the 5kg parcel was put on a plane back to California. Mongol arga. That can't be good for my carbon footprint. It looks like I'll have to find another way to get it over there. I'm thinking DHL instead of USPS+Mongol Post.

More importantly, the government is in the midst of dealing with a very serious H1N1 outbreak (Reuters article), resulting from limited access to vaccines in time for the beginning of Mongolian winter. 859 confirmed cases of H1N1, with six resulting deaths. In response, WHO sent 45,000 doses of Tamiflu to Mongolia, public places of entertainment (e.g., cinemas) have been shut down, restaurants and supermakets must close by 9PM, and schools have been shut down for two weeks (and instruction will reportedly take place via television).

A note on my absence from the blog. I've been delinquent on posting since early September because of, in order: Mayo Clinic Transform, my wedding, and work trips to Abuja, Doha, and Evanston. I plan to return to more regular blogging now, both here and at Global Health Ideas.

Design thinking + safe water: workshop report from Mexico

Cross-posted from the Global Health Ideas blog:

As promised earlier, here is a brief account about the design+water workshop I conducted in Mexico in June.

Two months ago, I was in La Paz, Mexico at NGO Fundación Cántaro Azul, helping them build organizational capacity in human-centered design (HCD).  Cántaro Azul works to improve access to safe water and sanitation for disadvantaged communities, not only in Baja California Sur, but in other parts of Mexico, and abroad. Their interest in HCD is two-fold: to improve existing initiatives and to innovate new approaches.

I recently completed the workshop final report for the organization. In the hopes that the work may be helpful to others, I'm posting the synopsis of the report here, along with some workshop photos. If you're interested in accessing the report, please contact me directly.

Design thinking workshop final report: Safe water options with rural community stores in BCS 

Fundación Cántaro Azul • La Paz, Baja California Sur, México 

Jaspal S. Sandhu, Ph.D. • July 2009 

This document describes the outcomes of a week-long design thinking workshop held at Fundación Cántaro Azul (FCA) in La Paz in June 2009. The workshop aimed to build design thinking capacity at the organization while working on a problem of actual importance to FCA. The most important practical outcomes of this workshop were two complementary models for providing a clean, affordable drinking water choice for rural people in Baja California Sur via community stores. The primary audience for this document is FCA. It is intended to help them with ongoing activities focused on the community store model and in incorporating this approach in their various activities. The workshop was designed and facilitated by Jaspal Sandhu, the report author. Workshop funding was provided by the Blum Center for Developing Economies at the University of California, Berkeley.

Shown below: Field research during Day 2 and Day 3 of the workshop. Top to bottom: (1) Using an auto-servicio system in La Paz; (2) interviewing a user at a rural, government-run purificadora in San Antonio; (3) debriefing after the San Antonio research; (4) and obtaining water samples to test from a home in Rosario.

[add links]

As promised earlier [LINK], here is a brief report about the workshop I conducted in Mexico in June.

Two months ago, I was in La Paz, Mexico at NGO Fundación Cántaro Azul, helping them build organizational capacity in human-centered design (HCD).  Cántaro Azul works to improve access to safe water and sanitation for disadvantaged communities, not only in Baja California Sur, but in other parts of Mexico, and abroad. Their interest in HCD is two-fold: to improve existing initiatives and to innovate new approaches.

I recently completed the workshop final report for the organization. In the hopes that the work may be helpful to others, I'm posting the synopsis of the report here. If you're interested in accessing the report, please contact me directly.

Design thinking workshop final report: 

Safe water options with rural community stores in BCS 

Fundación Cántaro Azul • La Paz, Baja California Sur, México 

Jaspal S. Sandhu, Ph.D. • July 2009 

Synopsis. This document describes the outcomes of a week-long design thinking workshop held at Fundación Cántaro Azul (FCA) in La Paz in June 2009. The workshop aimed to build design thinking capacity at the organization while working on a problem of actual importance to FCA. The most important practical outcomes of this workshop were two complementary models for providing a clean, affordable drinking water choice for rural people in Baja California Sur via community stores. The primary audience for this document is FCA. It is intended to help them with ongoing activities focused on the community store model and in incorporating this approach in their various activities. The workshop was designed and facilitated by Jaspal Sandhu, the report author. Workshop funding was provided by the Blum Center for Developing Economies at the University of California, Berkeley. 

FIG3 PHOTOS ASxxxx 

Neo-Nazis and shamans in Mongolia

The Nazi-themed Tse Pub in Ulaanbaatar, photo from June 2009 (credit: bartpogoda on Flickr)

Spoke with Sean on the phone yesterday and he directed to me to two recent MSM pieces about Mongolia. These certainly cover new ground for international reporting on Mongolia. One on shamans (my old apartment jijur left Ulaanbaatar in late 2007 to become a shaman in Hentii) and one on neo-Nazis (when I lived in UIaanbaatar's 11th microdistrict in 2008, there was a group of zaluuchuud who would cruise their oversized Nazi Party flag around the neighborhood in an SUV while flexing their tattoos).

Links and excerpts below.

Shamans’ Spirits Crowd Air of Mongolian Capital, Ulan Bator [sic] Journal, New York Times, 10 Jul 2009

Since [1992], shamans have flourished here and become a visible fixture of city life in recent years, offering exorcisims and fortune-telling on Web sites and professionally made street signs.

They are in high demand. Thousands of bureaucrats, laid-off factory workers and nomads who lost their herds in the country’s stumble toward a market economy now crowd faded Soviet-style apartment blocks and tent districts looking for work, love and healing.

“In the old days people asked for rain,” said Chinbat, 30, an electrical engineer who recently finished training to become a shaman. “Today they ask for money.”

The Neo-Nazis of Mongolia: Swastikas Against China, Time Magazine, 27 Jul 2009

The neo-Nazis may be on society's fringe, but they represent the extreme of a very real current of nationalism. Sandwiched between Russia and China, with foreign powers clamoring for a slice of the country's vast mineral riches, many Mongolians fear economic and ethnic colonization. This has prompted displays of hostility toward outsiders and slowed crucial foreign-investment negotiations.

Swine flu and chicharrones: lessons on sign placement (La Paz, MX)

At the end of June, I was in La Paz, Baja California Sur, Mexico working with Fundación Cántaro Azul, an organization that provides access to safe water and sanitation for disadvantaged communities in Mexico and abroad. I was there helping Cántaro Azul build organizational capacity to use human-centered design to improve existing initiatives and to innovate new ones. More on that in another post (I'm still delinquent on a final report, so the post will be 1-2 weeks off still).

This post is just photos of signs - and sign placement - that the team and I spotted in greater La Paz. (Actually, I think Lludmila spotted all of these.)

A temporary stall for childhood immunizations at a gas station...

... and the main sign is posted next to another sign that reads "DANGER".

"It's sadder to walk, isn't it?"

A poster from the Mexican Ministry of Health assuring us of the safety of pork - just below a display of carnitas and chicharrones.

Borrowing innovation: health services, financial services, and clean tech

Image courtesy of kiwanja.net

 

Cross-posted from the Global Health Ideas blog:

Late last week I read news from three different sectors, all about “South-North” innovation transfer, a topic we’ve discussed here before, particularly in the context of mHealth. Earlier this year Fast Company reported on the concept of trickle-up innovation, citing the examples of yogurt microplants in Bangladesh (Group Danone, Grameen Bank) and Mosoko, touted as Craigslist for the next billion in Kenya (Nokia). In addition to these cases of MNCs from the global North testing out concepts in the South, Fast Company presented examples of corporations from the South, including ICICI (banking, India), Natura (cosmetics, Brazil), and Goodbaby (infant products, China). 

Here are the three articles from this past week:

1. HEALTH SERVICES: To Fix Health Care, Some Study Developing World, Wall Street Journal, 2 Jul 2009. The University of Alabama-Birmingham AIDS clinic turned to Zambia for a model of increasing the number of patients who showed up for treatment. Based on early successes, they are continuing under the project name “Zambama”.
2. FINANCIAL SERVICES: DOCOMO to Launch Mobile Remittance Service, NTT DOCOMO press release, 2 Jul 2009. Later this month Japan’s DOCOMO will enable individual subscribers to use their mobile phone to remit money to other subscribers. Such a branchless banking/financial remittance service is certainly prompted by Safaricom’s M-PESA service from Kenya.
3.  CLEAN TECH: Worldchanging Interview: Shawn Frayne, 2 Jul 2009. The interview is about wind technology, but touches on broader issues related to South-North innovation flow. Frayne thinks that “the constraints of the developing world can provide the necessary inspiration to make significant technological leaps that can benefit the Global South and Global North simultaneously”.

There are various other examples from the last several years suggesting a growing trend in countries from the North learning from the South. Here are examples just around financial services for the poor:

• Opportunity NYC was the first conditional cash transfer (CCT) program in the U.S., based on the Oportunidades program developed in Mexico.
  
• Less than one month ago international development micro-lender Kiva launched a pilot program in the U.S.
• Grameen Bank supports microcredit in places like Norway

Add to that the various management principles we’ve learned from the Aravind Eye Care System and Mumbai’s dabbawallas. Extending the argument presented by Fast Company, these examples show that South-North innovation transfer doesn’t have to be focused on corporations.

While it’s enticing to think about mining untapped innovation potential in the South for the benefit of the North, the real potential is much broader. Innovation can (and does) flow in all directions, not just South-North, but also North-South, South-South, and within countries. The challenge is to learn from different ways of approaching the same problem. Or even similar problems: see how Kaiser-Permanente visited a flight school to reduce medication errors and how the NHS worked with Formula 1 team to improve ICU procedures.

Given this potential, the big, open question is this… How do we increase global sharing of ideas and models to spur innovation?

What can patients tell us about fixing US healthcare?

Atul Gawande's recent New Yorker article about the super-high costs of healthcare in McAllen, Texas has gotten lots of people talking. (If you haven't read it, you need to.) In the White House, President Obama made the article White House required reading, as reported by the New York Times:

President Obama recently summoned aides to the Oval Office to discuss a magazine article investigating why the border town of McAllen, Tex., was the country’s most expensive place for health care. The article became required reading in the White House, with Mr. Obama even citing it at a meeting last week with two dozen Democratic senators.

Data show that increased healthcare spending does not necessarily result in better health outcomes, and that the spending varies widely within the US. The Gawande article begins to answer the question of why this is the case, but there is a counterpoint (also from the NYTimes):

In his blog last month, Mr. [Peter] Orszag wrote, “The higher-cost areas and hospitals don’t generate better outcomes than the lower-cost ones.” But other researchers and politicians are not so sure. They say it would be a mistake to cut or cap Medicare payments without knowing why spending in some places far exceeds the national average.

What's as interesting about Gawande's article as the story is the fact that the national discussion has been altered by a quick case study of a single town in Texas. (Aside: this is why extreme case sampling is so valuable.) What else can we learn by studying individual systems, sitting down with real providers, and talking to actual patients?

This was on my mind yesterday when I was waiting for a San Francisco BART train in Oakland. A woman in her late 40s was standing near me talking to a much younger woman about her experiences with safety-net hospitals. The loud-enough-to-be-public monologue, roughly captured:

They brought the x-ray machine to me this time. I told the people from Social Services, "There's no way I can pay for all this". The doctor came and told me it was a pulled muscle, and to go home, elevate it, and rest. I did just as the doctor said and four days later - four days - I got a call saying "We made a mistake". Then he said "They made a mistake". I went to Highland - no Summit - and they showed me two x-rays side-by-side. In the last one my bone was out of its socket and my kneecap was broken in two places. I was in rehab for 12 months!

Themes relevant to the current discussion: cost of care, role of technology, quality of care, trust in providers.

This is stuff Aman has been thinking about for some time, so I expect him to write about it soon.

Posts from Global Health Council 2009 (GHC36)

I've been quiet here for the last two weeks because I was blogging - and not cross-posting - at the Global Health Ideas blog from the Global Health Council's 2009 meeting in Washington, DC. We should have a final synthesis up over at worldchanging.com early next week. For now, here's a link to our team's posts from the conference itself, newest to oldest:

• Magic bullets & usability for postpartum hemorrhaging
• Trust & social desirability in m-health
• No such thing as “HIV in Africa” (Hans Rosling plenary)
• Discovering new strategies using proven [mHealth] technologies
• Vouchers work, but there will be challenges (voucher-based health programs)
• Where’s the rest of the mother? ("low-tech" solutions for improving child health)
• Harnessing all facets of the private sector
• Blogging the Global Health Council (GHC36): Music to the ears

And here's the Twitter search over hashtag #GHC36.

Linking clinic design to health outcomes

Cross-posted from the Global Health Ideas blog:

In October 2007 I was working in a place called Suhbaatar, a province in the flat and often dusty steppes of eastern Mongolia named after the hero of the 1921 revolution.  The primary activity of this trip was to hang out with community health workers in different sums (counties), a few days in each place, in order to better understand the role information played in their provision of services. The last sum I visited normally has about 4000 people, largely pastoralist nomads, living across an area 1.5 times the size of Rhode Island, with roughly half of them concentrated at the sum center during the fall months. A rough spring for the local pastures meant that many of these 4000 had left on otor, pasturing livestock up to 300km away, making it downright desolate.

On my third day in this sum, I asked the doctor managing the local clinic for a tour of the new clinic being built across the street.  GTZ and Lux-Development had both been here recently on health infrastructure projects, but this time the money was coming from the Mongolian government.  The doctor, a nurse practitioner, and I walked across the street where we met the foreman, a man who had come here from the capital Ulaanbaatar (photo).  Though the work crew was already working on the roof – the construction had started two months earlier – I was surprised to hear the doctor, who had worked here for more than 10 years, asking some critical questions about the layout of the new hospital. After several minutes of interrogation, the exasperated foreman claimed this hospital was the same design as one being completed in another sum. What the doctor knew and the foreman didn’t was that I had just visited that sum.  “Is this true?” the doctor asked me. “Does it have the same number of beds?” “Will our hospital be as big?” “No” was the answer on all counts. In consultation with the nurse, the doctor quickly realized this new hospital wouldn’t provide enough space to meet their patient demands.  So they would have to keep parts of the old hospital working to meet their needs.  So much for the touted energy efficiency of the new vakuum sunh (double-paned windows). This was the result of a top-down approach to hospital design.

Earlier this week the New York Times reported on how health outcomes are driving hospital design in U.S. settings (thanks Dr. Marwah for the article pointer):

In many new hospitals and pavilions … semiprivate rooms have vanished. Single-patient rooms are now viewed as an important element of high-quality health care. The benefits of the single room emerged through evidence-based hospital design, a new field that guides health care construction. More than 1,500 studies have examined ways that design can reduce medical errors, infections and falls — and relieve patient stress.

The idea is simple: change the design of the physical environment to reflect the needs of the people in the system - patients, visitors, administrators, caregivers, insurers - with an eye towards improving health outcomes. There are opportunities both for new construction, but also for retrofits. And the solutions are often simple. From the Times article, Princeton’s University Medical Center is installing larger windows “because studies suggest that natural light can reduce depression and that scenes of nature can reduce reported levels of pain”. From a 2007 SFGate article, Kaiser-Permanente is changing the color of the paint on the walls “to cheery spring shades of pale blue, yellow and green” in an effort to be more patient-focused.

All good and well, but what do systems with limited resources have to take from this approach? Quite a bit it seems…

As an example, consider the recent PLoS study from Peru (Escombe et al., 2007) that showed how natural ventilation - an low-cost alternative to negative-pressure isolation rooms - could be used to reduce intrahospital transmission rates of tuberculosis. The recommendation of the study? Open the doors and windows: “Even at the recommended ventilation rate, the calculated risk of airborne contagion was greater in these mechanically ventilated rooms [in modern facilities built 1970-1990] than in naturally ventilated rooms with open windows and doors [in older facilities built pre-1950]“.

As this research shows there are plenty of opportunities to change the way we work within existing facilities to improve outcomes. And there are plenty of opportunities with systems that are renovating and building new hospitals and clinics. A couple current examples: (1) the Millennium Challenge Corporation is renovating 150 health centers in Lesotho; (2) the Asian Development Bank is building 17 new clinics and renovating 7 facilities, including 3 provincial hospitals as part of the Third Health Sector Development Project in Mongolia (PDF).

The human-centered approach can improve health outcomes with simple innovations derived from a better understanding of the needs of a facility’s users. The open question is whether we’ll take advantage of such an approach or whether - in the words of   Roger Ulrich from Texas A&M’s Center for Health Systems and Design - we’ll simply “pay lip service to the evidence”.