Updates on Phones

I have a few updates on the work I've been doing with mobile phones. But to get updated, you'll have to click at least one more time (twice if you want the video and the blog):

Video:

http://www.youtube.com/watch?v=AxJ3PBeOZ5Q

Nuru Blog:

http://www.nuruinternational.org/blogs/research/farmersfightingpovertywithnokiagoogleoperaandsafaricom.html

How to Setup a Mobile Data Collection System

What I Did This Month

This week, I’m going to talk about exactly what it is I’ve been doing these past two months. My major goal was to set up a data collection system for Nuru. We had decided that phones were the way to go, but which phones, and what system still needed to be answered.

For the phone search, I went to Kisii, the nearest city (>100,000 people) and I selected a few phones that met my needs. #1 Internet (GPRS) #2 Java (ability to install software) #3 Camera #4 Not a “China Phone” (a brand-less or knock-off phone) #5 Were not way more expensive than other options. I found four phones which met those criteria: Nokia 2330, Nokia 1680, Samsung C-450, Samsung E2120.

I bought four identical SIM cards, and began the testing. The field testing consisted of their ability to connect to the Internet, a subjective test of their user interface, and their ability to connect to the web at all the important locations in our area (and some intentionally low reception spots). I also did an aesthetic survey, showing them to those who would be using them and asking them which they would prefer. I installed the relevant software on them (or tried to; Opera Mini 4.2 for Google Forms, and SMS:Frontline Forms). I then gave points for features above and beyond the 5 listed above (e.g. one had a microSD slot, some had video cameras, etc). I was concerned that my arbitrary weights and criteria would leave me without a conclusion. But I was mistaken, as the Nokia 1680 blew the others out of the water; it was the best in almost every single category.

Having selected a phone, I began to test the platforms and do a cost comparison. The major competitors were Frontline SMS (the leading SMS-based data collection tool) and Google Forms (a web-based data collection tool). The capabilities of Google Forms far exceeded Frontline. The major benefit of Google is that it’s “in the cloud,” that is, it’s stored “on the Internet” and not on any one physical computer. Which means that a computer crash (as happened to me yesterday) wouldn’t destroy any data and that data would be accessible in more than one place. The other factor was operating costs, and with Google Forms, they’d be about one hundred times lower than with Frontline. Data is super cheap, about a dime per MB, and form submission is about 5KB; SMS would cost $0.03 each form.

Then came the process of looking for a place to buy the phones. I went with Philip to Nairobi and looked for a place to buy phones. I went around the city with Philip’s son, Laurent, who knew the city well. After realizing that the Nairobi phone book was a joke (I gave up after 0 of 15 numbers connected to a business in the category I was calling), and that all the retailers in Nairobi were getting their phones from the Safaricom dealer, we went there. The phone retailed at 3000/- (~$40) and they gave us a whole 50/- discount when they heard we were buying 100 pieces. So we kept looking. My friend from Stanford put us in contact with people from the University of Naibori, and they tipped us off to a wholesaler. And they cut us a deal: 2850/= per piece. And since we were new customers, they agreed to ship them for free.

After this, I had to figure out the best configuration for the phones. For network, I decided to start with Safaricom as it had the clear majority of the local business already. I wanted people to keep their phone numbers and not have to change networks on top of all this new phone business. I realized after buying 100 phones, that the browser I installed (Opera 4.2) would crash fairly regularly when it viewed a Sheet. While not a critical operation (our main goal was data input), it would still allow us to do a great deal more if we could view the data that was submitted. So I started scrambling. And eventually found a link to an older version of Opera (2.0) that worked and wouldn’t crash and ran faster on the poor under-powered phones.

While Google Forms can work with any Google account, it works even better with a Google Apps deployment because you can securely record who submits data. Our amazing tech guy Will Kerr registered www.nuru.co.ke for us, and linked Google Apps to it. I created a very basic Google Site to allow for easy navigation of available forms. I then registered accounts for all the staff and started the tedious task of programming phones.

I know there’s probably a way to clone phones using USB, but after hours of trying, I had failed completely; USB is technically unsupported on the phone and I’d have to hack it, even assuming I could find the right cord (which is no easy task). I decided that doing it one by one was the only option. So I used the phones’ email client to access their new @nuru.co.ke addresses, installed Opera, added a bookmark to the Nuru site (thank God for bit.ly!), and for kicks, added the Nuru logo as the phone’s wallpaper. Wash, rinse, repeat… a hundred times. I got really good towards the end. In my personal time trials, my record was 8 minutes, 9 seconds for a complete setup. I eventually realized it was mindless enough work that I could learn about God, ethics and human nature simultaneously by listening to the Brothers Karamazov on MP3 while programming the phones.

Last of all was training. I trained and trained and trained. For most of them, they had never used a computer before this. And now they had to grapple with concepts like “megabytes” and “internet.” It was slow going, but rewarding. My lesson was once interrupted by a spreading wave of fake shutter sounds, as one person figured out the camera and then spread the knowledge like a virus. I’ve heard numerous accounts of people Googling and Wikipediaing late into the night about topics as varied as “rich people,” and “mountains.” These people had never even had access to a public library, and now they have all the world’s knowledge open to them. So training took a very long time with each group. And even after hours and hours of training, people are still uncomfortable with the phones. And this is why I’ll be spending a few more weeks on training when I come back.

In addition to training the Kenyan staff, I started showing the Foundation Team about the phones and about Google Forms. And I experimented with the Forms myself. I found that there is incredible power to be unlocked in Forms, particularly in the ability to link different Google Sheets and display the output in an HTML table (essentially it can pretend like it’s a database). This means that we can have all of our data on our handsets.

So that’s what I did the last two months. It’s been a really incredible experience. Looking back on it, I’m excited about the state of the world. This would have been impossible even last year. Google has invented a system for easily collecting data. Safaricom wanted to make money selling phone internet access. Years ago, Opera made a way to view web pages on a phone. Nokia built a high-quality phone at a low price. And I, with no special experience or programming knowledge, am able to piece together these technologies to make a cheap, real-time data collection system.

What’s so exciting to me is that I’m nothing special; anyone could have done this, and done it cheap. It only cost Nuru the cost of my time to set this thing up, $30 per year to register a domain, and $40 per phone with about $1 per month in data charges. There are no development costs, no programmers to be paid, no server costs. Anywhere there is GPRS internet (which is quickly becoming everywhere), this kind of system could be set up. This blog isn’t patented. So please, rip off this idea! And encourage others to, also!

Revolution

You all know that the world is flat. If you don’t, you need to read Thomas Friedman’s book, “The World Is Flat.” Basically he says that cheap communication (i.e. the Internet) has “flattened” the world; barriers of space, geography and culture are becoming irrelevant because of the ease of communication.

So the world is flat. But what does that matter to a Kenyan farmer? To someone making $1 a day, even a $400 computer is far beyond feasibility. And that’s not even considering the lack of electricity and computer knowledge which seem as endemic as malaria.

If you’re a computer nerd (or you know any), you know they’ve been talking about ‘think clients’ for about forever. We nerds have long dreamed of getting access to computer horsepower far beyond what we could afford using a “thin,” cheap computer whose only purpose was connecting to a big, powerful one, one where all the real work was done and big data was stored. But computers got so cheap so fast that this never really worked out. Cheap, at least, for the developed world.

But there are billions for which a computer is completely inaccessible. Even the $1 per hour for computer use is unreasonable. Enter: cell phone. It’s the thin-client that we nerds have been yearning for. And the internet is just now getting mature enough to simultaneously handle the big tasks and to present it to the kinds of processors found on cell phones. So what do we have? We’ll have, within a decade, poor people across the world accessing the fullness of the internet.

Who should care? Everybody. Do you have something to sell? You’ll have a billion customers within a decade who have phones, internet access, and the ability to send money over phone networks (in Kenya, it’s called M-PESA and you use local businesses as ATMs; you can deposit and withdraw money from your phone at almost any shop or stand). Do you want to distribute Bibles? For the cost of a few Bibles, you could give a person access to the Bible in every language and every piece of Christian scholarship ever written. Do you want to communicate your message? There is an entire generation of the poor that will soon discover it can read whatever ideas that interest them, be they democratic, communistic, consumerist, atheistic, Christian, Muslim, patriotic, or racist. A billion potential readers. A billion sets of eyeballs. A billion wallets. A billion hearts. Gutenberg’s printing press gave millions access to the printed word within a century of its invention. The cell phone will reach exceedingly more people in its second decade than the printing press did in a century.

So where does Nuru fit in? How are we positioning ourselves in this revolution? We are planning to accelerate it. We want our people to be on this cutting edge. We have purchased and will soon be issuing internet-enabled cell phones to all our staff within a few weeks. We’ll teach them the basics of how to use the phones to communicate, how to use email, and how to use the internet. And then, we’ll use some of the newly matured internet tools to do Nuru stuff better.

Google Forms provides an incredible platform for collecting data. We can design forms, send out the relevant URL, and then get people to submit data by phone and have it compiled onto a safe, secure, shared server in San Jose . That means that all of our operation can, with a few thousand dollars of phones, become completely digital. No more paper attendance forms. No more written ledgers recording contributions to savings accounts. No more survey sheets. No more lost home visit forms. No more paper. All digital.

But this won’t just let us do what we used to do better. It will let us do what’s never been done before. Do we need to make an announcement to all 60 Nuru staff members? Now we just need to send out an email. What about taking a staff-wide vote on a course of action? It’s as simple as emailing out a Google Form.

I talked before about the Disease Intelligence Network, a system for monitoring and rapidly responding to outbreaks. But now it’s actually possible. We can do continuous surveillance (i.e. taking temperatures), uploading this data to a server as it is collected. The instant certain conditions are met (e.g. fever prevalence >10%), we can have the computer alert the healthcare team of an outbreak of disease.

There is a multitude of other things that we can do but don’t realize we can do. An entire universe of possibilities will open up in three weeks. I just need to keep my head on straight and make sure we master the basics first.

Turnover

So it begins. I am now officially a Research Officer. I’m on a special assignment the next seven weeks to get a data collection system set up for the Poverty Intelligence Network (a revision of the Disease Intelligence Network… all this is in the blogosphere if you’re really interested). I’m going to work on data: how to use it, how to gather it, how to teach others to use it.

So today I started a new job. But in the same place. It feels somehow like I’m leaving, but without going anywhere. I’ve officially handed over my position to the wonderful Janine Dzuba. After the break in April (all Western staff out for a few weeks allowing the Kenyans to run the project alone for a while), I’ll be taking back up the healthcare reigns.

This last week, I’ve been spending all of my time transitioning with Janine, the now Healthcare Program Manager. This was quite challenging. Simply in terms of information, there is very much which needs to be communicated in a very short time. We had only 3 days; most transitions happen over the course of 3 weeks. But Janine had been staying in the loop by weekly calls with me for the last few months (isn’t the flat world wonderful?).

Nevertheless, it’s impossible to communicate the situation here over the phone. Or at least I wasn’t able to. So in coming here, even though she was here just six months ago, she had much to learn and adjust to. She’s been drinking from a fire hose the last few days, and doing a great job of it. Visiting the clinic, meetings, conversations, lunches… and so on… and so on.

And for me, it has been hard for me to remember all the things I’ve been doing so that I can tell her about them. You, my faithful blog readers, have only gotten to read of a few of the things that have been happening. There are a million little details of the program: which forms I use, how I run meetings, the where/when/why/how/who about meetings.

The turnover was hard in another way as well. We didn’t agree on everything. Janine thought some of the things I prioritized weren’t as important. Some of the things I had ignored, she thinks should be emphasized. So what is there to do? The thing to do is to give it up; that’s what a turnover is about. There is no room for ego; I have had to give up my programs faithfully and fully to Janine. Then she can lead them forward with her strengths and weaknesses, complimenting my own. It’s wonderful to have another critical mind working on this project. It has been wonderful (though sometime painful) to have Janine’s keen mind asking keen questions about the way things have been going. And this is exactly how we get better.

She’s going to do (and doing) things differently from me, and that’s a good thing. It shows the Kenyan staff a different style of management, allowing them to hold on to the gems of each program manager and throw out the rest (there are plenty of habits and styles which I would not want emulated). It also makes the CDC the constant ones. The only relationships which really last are those with Nuru Kenya, not Nuru USA. This rapid rotation and frequent turnover forces independence.

I’m really excited to see what she does with the program over the next few months. There are some really exciting things in the pipeline for sure! We have a child’s health day, a mobile clinic and the initiation of the Community Health Worker training, just to name a few. I’m a bit jealous of her, but not so much that I’d give up nerd-ing out with the research team. I can console myself with being able to reap where I haven’t sown, so to speak; I get to come in with all these things set up and make them better still when I come back in May.

David

Information Infinity

What can one do with access to all the world’s information? How could knowledge help farmers in rural Kenya? What if they could easily communicate with anyone else in the world?

Before I attempt to answer these questions, really think about them. This is a period in human history without precedent. Seriously take a moment and reflect on how the world has fundamentally changed in the last decade or two. There are certain patterns of development that repeat in developing countries, but never have the poorest and least developed had anything near good access to information.

The legends of the US bear with heroes as diverse as Ben Franklyn and Andrew Carnegie attributing much of their success to a unique access to information. In their case, they could visit libraries with a few hundred books in it. Now everyone who can save up $50 has access to a billion volume library. For about $50, a cell phone can be purchased with a camera and access to the internet. This is still expensive, but not impossibly so.

In 1700 BC the fastest communication was by horseback. In 1700AD the fastest communication was by horseback. From 1700AD to 2010AD, communication got about 10 million times faster. For a penny, I can send a message from anywhere in Kuria at the speed of light to anyone in the world.

But what does this all mean? Not too much yet. It means that we can coordinate a bit better with our Nuru staff and that you can inform people if you’re running late. The true power has yet to be realized. But it’s so hard to think in a way that’s never been thought before.

And that’s my job starting February 11. I am handing over Healthcare Program Manager to Janine Dzuba for two months while I step into the role of Research Program Manager. I am going to attempt to set up a system for communicating and collecting data. The primary thrust of this will be to distribute data collection tools to our leaders, that is, cell phones. We’ll have 50 people, some measuring fevers, rainfall, school attendance, savings rates, and agriculture yields. This will give us the ability to collect and organize pictures of farms at various stages, confirm the straightness of their columns, do remote diagnosis of medical conditions (“telemedicine”), and possibly even identity confirmation using Picasa.

I’ve written earlier on the Disease Intelligence Network (DIN), the concept that we could potentially respond rapidly to fluid data. Starting next month, I’m going to start work on the Poverty Intelligence Network (PIN). I want to get a good look at what’s going in Kuria, fast, slow and everything in between.

Nuru has a unique position when it comes to data. Most aid agencies aren’t so interested in data. Those that are care more about numbers and less about the accuracy of those numbers. Or at least they don’t seem to care as most of the data that is getting fed to them is at least partly bogus (a fact which they could find out if they really wanted to).

Researchers do care about good data. But they’re hindered because grants must be spent only on research and not on ending poverty. A Malaria epidemiologist can never really help a community directly (at least not as part of his day job). He’s helping humanity in general, but not that particular community. With a researcher strictly doing his job as a researcher and nothing more, the community is unlikely to offer any more than lukewarm support. The other challenge with research is that it’s extremely silo-ed. You have to specialize; you have to ask a single focused question.

Nuru is unique. The data, while critical, is not our end. The people are. The data serves the people, not vice versa. As such, we have incredible buy-in and support for our work. People will answer awkward survey questions they wouldn’t if we were just strangers.

We are also not constrained by the hyper-focus of science. We can collect data on all different program areas. Then we might see relationships we didn’t expect. Maybe malaria rate has something to do with maize yield. Or water source with savings rates. There are probably a thousand relationships which we may be able to see because we don’t have to start with one specific question.

All that to say I’m excited. There are a billion things which could be measured, but what matters? What’s helpful? What’s accurate? I’m still looking for ideas if you have any (the crazier the better).

I hope that I can begin to take advantage of the unimaginable potential of infinite information and limitless communication.

Travel

This week, I just arrived. Nothing has really happened yet, so I’ll just write about what did: a 49 hours and 52 minutes of planes, trains and automobiles, except without the trains. Which is the shortest amount of time it’s yet taken to get from my door in California to my door in Kenya. And, my dear reader, I pray your forgiveness, for I have just finished Tom Sawyer and I cannot but retain some nineteenth century vocabulary and Twain sarcasm in my voice. It may wear off by and by.

My alarm clock started beeping and I my heart leaped with the anticipation of the tortuous few days ahead of me. I would have awoken on sunny Sunday in Temecula, California in my parents’ home, but it was before sunrise and so not very sunny. I did some last minute packing of things I had forgotten, and then got in the car, Dad driving and Mom asleep in the back. She was feeling bad, for she was ill, and so went to sleep in the back seat. Dad and I passed the time by discussing theology and science, two of our favorite subjects.

We travelled at or above the speed limit for the duration of the time, for there were few other unfortunate souls on the road pre-sunrise on a Sunday. And we were able to witness a miracle which comes but a few times a year, Southern California roadways which are uncongested and thereby functional.

After breakfasting at McDonalds (or rather in the car outside a McDonalds, as they had decided to keep guests out of the restaurant by having the air conditioning on), we arrived at the airport. I was dropped off and waited in the first of several lines. It passed slowly, and I had the good fortune of seeing my esteemed teammate Vivian Lu while in line. Time slowed, as it always seems to do while in a line, but I managed to make it through and check my bag. I waited in another line and went through that strange and loathsome ritual of undressing before a hurried line of travelers and dreary eyed TSA officials. Belt, shoes, pockets. *Beep* Watch.

I redressed an approached my first gate. I had the good fortune of avoiding the dreaded middle seat, and had the chance to view the beautiful Southwestern countryside for this first short leg. The unfortunate soul beside me was friendly but not so talkative. And though I do revel in conversing with strangers (at least early in my journey), I am aware that I am in the minority and so try to respect the square foot of privacy beside me.

Vivian and I arrived in Houston. The few hour flight was not so wearisome, and it seemed about morning, though what time the clocks said I cannot now remember. We waited for our next flight for a few hours in a crowd of people who had built up single-chair airport fiefdoms, strong with mental fortifications against interacting with their equally-well fortified neighbors.

We boarded this next flight and were presently en route to Paris. The passengers were a strange assortment of well-dressed Europeans, Texan-dressed Texans, and poorly-dressed us. We boarded the 777, and I retained my fortunate position near the window and Vivian had the

This next trip was quite a bit longer. Something like 10 if I remember. The plane took off, went through the clouds, and my view went from a monotony of white to a monotony of black.

I remembered the illness with which my mother was afflicted as it seemed to be the one which had decided to choose me as its next victim. A decongestant helped, but my misery began. My thirst and subsequent drinking transformed my nice window seat into prison cell, locked by two sleeping people beside me. I escaped when one or the other stood up to seek a similar relief.

I passed the time by listening to the Autobiography of Benjamin Franklyn. He was a rather interesting fellow, and it made the trip speed by, though my focus wanted towards the end for want of sleep, my burgeoning illness and my back pain (a long-time friend, who always accompanied me on such journeys).

And so we arrived in Paris. The funny thing about France is, firstly, that everybody speaks French. But by some sorcery, everyone was able to figure out that we were not in fact French, but Americans. But for spite, I think, they still started in French. I would ask if they spoke English, they would betray annoyance, and then continue in English. I was glad it wasn’t the French equivalent of “Why don’t you talk ‘Merican?”

On the plane, we had noted the pilots indication that the temperature outside was 17 degrees Fahrenheit. I, being from California, did not understand what this meant. It was surely colder than normal cold California weather of 60 degrees, but impossible for me to estimate. I think I supposed 50 degrees was right around as cold as things got, so steeled myself for that. I was dressed for California/Kenya weather, and so was equipped with a long-sleeve shirt and a pair of slacks. I figured I should steal a blanket from the airplane as it would probably find some use in the new cold land.

We wanted to find our next flight; the time was 12 hours away and the terminal about a thousand miles away by foot. Let the reader beware: Charles de Gaulle airport is very large. Everything was ready so we had about 8 hours to spend in Paris. So we walked outside.

It’s difficult for me to describe what 17 degrees feels like to a Californian wearing a light shirt. Words like ‘soul-sucking’ and ‘*%*#’ come to mind, but fail to capture quite what it was like. Vivian had a two-layered jacket and graciously offered me the outer shell. This made deathly cold into I-want-to-die cold, and permitted the exploration of the city. Vivian adapted the Continental Airlines blanket into a scarf.

We took the train into town, and attempted to buy a day-use city subway pass. This simple task was quite difficult as the cold had significantly impaired my cognitive abilities. But we figured it out and retreated into the bowels of the subway where at least we wouldn’t die. For the next few hours, we explored the city, choosing an attraction, popping up from underground for just long enough to photograph it, and then retreating to the warmth of the subways again. In this manner, we were able to see Notre Dame, the Eiffel Tower and the Arc de Triumph.

The grandness of these three struck me. My mortality was always in my mind because the cold was constantly threatening it; the destinations each had an analogous effect: making me feel small and insignificant. Though constructed in very different ages, they all seemed to say: you’re small and unimportant. Notre Dame, because God is so great; the Arc, because the French military is so great (I was successful in suppressing any audible laughter); the Tower, because the Human Mind is so great. Anyways, with what remained of my vitality, Vivian and I travelled back to the airport; we had a few extra hours, but as night fell, death surely awaited us in any unheated place.

We went through the security ritual again, we boarded our last plane, and took off for Nairobi. Perhaps because He felt bad for the joke of the French weather He played on us, God smiled warmly on us in the plane. We had been upgraded to Business Class! It had been some time now since I had slept, and so I was looking forward to the reprieve. Unfortunately, my illness was intent upon making my remaining journey as miserable as possible. With malice, it pressurized my sinuses (which is a cruel trick in an airplane, I’ll have you know) and made my nose run like the Mississippi. By the end of the journey, my nostrils were so chapped they were almost bleeding. But I was able to get a few hours of sleep in the warm plane under a warm plane blanket, the horrors of the preceding afternoon drifting away.

I awoke a few hours before landing, my sinuses in open rebellion (but not so open as to be depressurized). We landed, got our visas in short order, and went to wait for our bags. We waited. No bags. And waited. No bags. And waited. No bags. We went to the window to file a claim for our bags, but a dozen passengers had given up hope before us and so were in line before us. Though it was five lines of information about us and our bags, the process took no less than twenty minutes per passenger. I had taken a decongestant which was presently affecting me adversely and not really doing much else. My patience grew short as the line didn’t. Finally, after what must have been about three weeks in line, we were served. My alacrity waning, I provided my information as best I could.

What follows may be lacking in accuracy because either for lack of sleep, the back pain, the sinus pain, the nostril pain, or the general malaise (or some combination thereof), I no longer maintained full consciousness. I would have loved to it if my affliction would have been so kind as to render me unconscious, for then I would have remembered none of the forthcoming torment. And I also would have loved it to just leave me alone. But alas, it knew exactly what I didn’t want, and gave it to me.

We met our fellow travelers who had arrived before us and together left the airport. We got in a car, and headed for the bus stage. Nairobi traffic is quite interesting and unlike most places. Some developing country traffic arrangements are quite chaotic, with little regard for lines or directions. But Nairobi seems to be a patchwork. In places, there is the utmost of order. And then sometimes it is customary for drivers to pass on the wrong side of the road simply because an opportunity presented itself. But we arrived at the bus stage after about an hour or two. That’s a guess, but what I do remember is a lot of not moving.

The bus stage is a unique place in that it is positive, tangible evidence to the Atheist that hell does indeed exist. It seems that all of the most worthless and unsavory characters have been sentenced to reside in what is literally a hot, steaming pit of filth. So, like Dante, we descended into it, but without the help of a guide so kind and helpful as Virgil. Seeing white faces brought a swarm of these tormented souls to our ‘assistance,’ desiring to ‘help’ us carry our bags for a ‘fair’ price. One swooped in for one of our bags, and I blocked and then proceeded, hoping that they’d go away if we ignored them. But unlike stray dogs and pimples, this did not work. They followed in train, and we ducked, pushed and swam through the throng.

We made it onto the waiting bus where at least the conductor kept most of them out. We then had to wait in the pit in the bus until it got full. We were about the third on the bus, which had a capacity of fifty. It was a large bus, like Greyhounds back home, but without any of the luxuries and moved to an equatorial latitude. I had the unfortunate need now to use the toilet. There was a ‘rehabilitated public toilet’ a few hundred meters from the bus. What it had looked like before the rehabilitation is impossible even to imagine. I was charged 10 shillings to urinate surrounded by filth indoors; I suppose I could have saved the 10 shillings and urinated surrounded by filth outdoors. I returned to the bus, somewhat relieved.

So we had some time to wait. I, now fully in torment from illness, hotness and pain, sat on the aisle seat doing everything in my power to hold on to hope and lose consciousness. But while hope fled, consciousness remained as every ten minutes a person would not walk sideways down the aisle and give me I solid bump with their hip and promptly not apologize. I say every ten minutes, but it wasn’t that; for even the luxury of regular bumps eluded me and I was bumped, it seemed, whenever it was that I was about to escape into sleep.

After about three or four eternities, the bus began moving. I have a vague recollection of this being, in clock-terms about two hours. We started moving at about noon, and thanks to the very mercy of the Almighty, didn’t stop until we arrived. All I remember of these next hours was misery. I was able to slip away for a few moments, but it was probably just to add to my misery in re-realizing again and again that I was and would long be in agony.

Finally, we arrived. We walked about half a kilometer to home, carrying our bags, relieved to be off the hellish bus. As we met friends along the road, all were greeted warmly but me; when people greeted me, they seemed somehow frightened. Which, if I looked one tenth as bad as I felt, would be the appropriate reaction. But we finally, finally got home.

49 hours, 52 minutes, 48 seconds. A new record.

Human Rights and Sustainability

The other night, a man came to the health center. The only nurse, Stephen Sangara, works eight hours per day and then sleeps on the premises. But he’s on call 24 hours a day, every day. The man awoke him, shouting in the night. Mr. Sangara came to the gate and opened it. The man is standing there with his son who has a bean stuck in his nose.

Immediately to the patient’s right is a wall-sized painting of his rights. Though he can’t read them (because they’re in English; MOH loves looking Westernized), he fully understands them.

Mr. Sangara opened his office and asked the man for payment (40/=, ~$0.50). The man said he had nothing, but he’d get it later (which he never did). In the exchange, he was rude to Mr. Sangara partly because he had to wait for him to wake up. And according to the Rights Mural, he has the ”Right to timely services” and the “Right to Optimum Care by qualified health Care providers .” His rights are clear, are extensively listed, customer obligations notably omit payment. He was annoyed in being asked to pay; paying for medical service is not mentioned as a customer obligation.

For reasons that are beyond the scope of this blog, the Ministry of Health (MOH) cannot reliably keep its health facility operating optimally. There is never enough staff, so wait times are very long in most MOH clinics. The supply of medical personnel comes from Nairobi and is doled out according to need. And the need is always too great.

Medication resupply shipments come in with random supplies at random intervals. They’re supposed to come every three months, but sometimes it’s five months between shipments. They’re supposed to be filled with medicines based on patient loads, but it seems quite random (we have about 40,000 condoms and almost no antibiotics).
So health facilities have two options. The first option is to violate customer rights #1 and #2, the right to “Optimum service” by not providing the drugs patients need and the right to “Timely service” by not having sufficient staff. This is what most clinics are forced to do. The other option is to add a customer obligation: the obligation to “Share in the cost of treatment.”

Those who chose the second option begin acting like private clinics. They buy medications from local pharmacists (which are always in stock) and sell them at a premium. The premium then goes to hire casuals, nurse assistants and clerks to help with patient management.

But when they sell drugs, people are angry. Even one of our good-hearted entrepreneurial boda drivers felt cheated when he was charged for medicines beyond the flat (subsidized) government rate. He went on and on about how they were very “funny” [devious] people at the hospital. The very people who used a bit of business sense to provide better treatment to their patients are perceived by the community as cheaters. Because, after all, people have a right to optimum service. And you shouldn’t have to pay for rights.

Maybe free healthcare for all should be the goal. We (theoretically…maybe…I hope) can afford it in the West. But Kenya’s not there yet, even counting foreign aid. So in the meantime, most government clinics have chosen to do their best to provide decent service to as many as they can, bearing the scorn of those who feel their rights have been violated.

Nuru aspires to sustainability. That means that we want our programs to be running full-steam without extra Western money within 5 years. And the “Healthcare is a right” worldview makes sustainability extremely difficult in the absence of a reliable well-funded government system. Every price increase, every user fee, every shilling asked for at a clinic is a perceived violation of rights.
People here have been told all their lives that healthcare is and should be a handout. Nuru’s No-Handouts ambition is confronting that view head-on. Our next major step is figuring out a mechanism for doing that. Do we increase fees at the clinics? Do we try to offer private options? Can a health plan or insurance plan be a financing mechanism? The real question is: do people value healthcare as something valuable enough to be paid for? Or are they satisfied in accepting whatever the government can hand out? And, an even harder question, if they see it as valuable for themselves, would they be willing to contribute so that the less fortunate can have it?

Is there a fundamental human right to healthcare? Let’s leave that to the philosophers (or me on my personal non-Nuru affiliated blog). But from the perspective from one on the ground, the idea that healthcare is a right has proved to be a significant obstacle to actually providing it.