(This entry was inspired by Jonathan Lewis’ blog entry on the Huffington Post and Social Edge, where I have cross-posted these thoughts.
Science seeks the truth but frequently does not arrive there, at least at first. The consequences can be mistaken beliefs and misguided practices that become so entrenched that they are almost regarded as laws of nature. The practical effects of science-gone-wrong can range from bad medicine to bad policy to microfinance dollars misdirected.
Jonah Lehrer, writing in The New Yorker last December (yes, I recognize that is not a peer-reviewed journal), cites some of the problems of science, and I borrow heavily from his piece. Scientific journals - not just People magazine - like exciting stories. This biases them towards publishing surprising findings with statistically significant positive results. One study showed that in 97% of all published studies authors found the result they had hypothesized - an outcome attributable both to authors’ and journals’ preference for publishing only positive (not “null”) results. This creates a skew away from objectivity. John Ioannidis, of Stanford, examined the 49 most cited articles in three major medical journals. Most of these studies were widely heralded randomized control studies. Forty-five showed positive results.
These positive biases can set off scientific feeding frenzies to find more and more nuance related to new, hot scientific “findings.” Alas, these, too, tend to reinforce questionable results, for identical reasons. Statistical analyses suggest that the results of small follow-up studies, rather than reporting results that are randomly distributed around a true mean as statistics tell us they should be, overwhelmingly tend to report results that are more positive. Even authors who produce highly original scientific claims find that they cannot easily find a publication outlet for their own subsequent studies that weaken or contradict them.
How can these biases be so prevalent? For one, science is less objective than we may believe. As an example: Does acupuncture work? Over a thirty year period, forty-seven studies in Japan and China showed that it did — every time. During the same period, studies in the West showed positive effects of acupuncture only half the time. Why? Because our expectations shape our perceptions. And this phenomenon holds in medicine, genetics, psychology, and presumably every other field of study. So why not microfinance studies?
One way these insidious influences creep in to influence scientific outcomes is through measurement errors. Even in randomized control trials, frequently considered the gold standard in mircofinance, there still may be the need to measure subjective “outcomes” like “made a good business investment,” or “benefited from training.” Evaluators may see what they want. Another problem is experiments that are simply not well designed.
As a practical matter, perhaps the biggest risk of making key go/no-go decisions on the basis of scientific evidence alone is that mistakes are rarely noticed, and more rarely undone. Of the 49 studies Ioannidis looked at (remember, these were the most cited in medicine), only thirty-four were replicated, and of those, two-fifths were contradicted or showed markedly smaller effects. Worse, he looked at nearly 450 claims about the effects of various genes on disease. Of these, only one was consistently replicable - less than ¼ percent of the sample
Unfortunately, these results often become scientific lore, difficult or impossible to dislodge and continuing to influence clinical practice even after they have been disproven or weakened.
Add to this problems with methodology. David Roodman reported that the Journal of Money, Credit and Banking found, upon trying to replicate the results it had published, that errors were commonplace, even if they didn’t always materially affect an article’s ultimate findings. The context for Roodman’s report is itself a rather testy, public debate about math and causality that he and Jonathan Murdoch found themselves in with Pitt and Khandker when they tried to replicate the latter’s microfinance results using the same data and methods.
What is the sum of all these observations: 1. The endeavor of doing science and publishing scientific results is fraught with mistakes and biases, despite all efforts to avoid them. 2. Mistaken ideas get extended, developed, and can take on the status of scientific fact. 3. Policy decisions flow from these results (which can lead to bad medicine or bad microfinance). 4. Mistakes are much less rarely undone than we’d hope once they achieve such status.
Given this situation, can we afford to place all our eggs in the basket of scientific experiment? Isn’t it wise to listen to voices of the field, even if we know they might be shading the truth to bring benefits to themselves?
I’m no science-basher. I am a scientist. But the lives of desperately poor people are at stake. If we continue to provide support for methods of microfinance that aren’t completely effective, our losses will be modest compared to discontinuing support for ideas that are helping the poor lead more productive lives, with more dignity, even if science tells us they shouldn’t be.
June 2011 Archives
(This entry was inspired by Jonathan Lewis’ blog entry on the Huffington Post and Social Edge, where I have cross-posted these thoughts.
Funding poor students could be the next big thing in microcredit and other innovative forms of microfinance that are so new that they don’t even have names.
Microcredit is put to many productive uses: as a cushion against the financial ups and downs of poor people whose lives are so uncertain and so fragile, as support for helping them launch or expand small micro-businesses, and to pay for unexpected “life events” such as funerals or weddings. None of these is a proven way out of poverty, whereas offering someone the opportunity to receive a college education or training as a skilled tradesman is a much surer path to a brighter financial future.
More than 850 million people worldwide lack basic education.[i] Of these, approximately 40 percent are out-of-school children and youth while the rest are illiterate adults. Many factors account for this including direct costs from school fees, tuition, books and uniforms, etc; opportunity costs from families forgoing the income their children would earn if they were working instead of being in school; and gender discrimination and other cultural norms.
Among those with a high school education, only 24 percent worldwide go on to receive a college degree or specialized technical training. This statistic drastically exaggerates the picture in the developing world where, for example, the figure is as low as 10.5 percent in India and just 7.5 percent in China. Lack of funding is often the underlying reason. For instance, if India is to achieve the worldwide average, more than 35 million Indian students will require funds.
Poor families understand that their children’s education can result in increasing their lifetime earnings and help their entire families escape poverty. Often as little as $100 to $500 can fund a year of education in a developing country,[ii] an expense most families still cannot afford. Loans for education are typically nonexistent, and when they do exist families fear being crippled by indebtedness from high interest rates. Yet there is compelling evidence from conditional cash transfer programs (where financial benefits are tied to school attendance) to indicate that properly structured incentives can dramatically improve school enrollment, attendance, and achievement[iii].
New models for funding education for poor children are being tried throughout the world. Below are two examples which together suggest the range of variations being explored. One is a nonprofit, the other a for-profit; one raises small amounts of money from desktop lenders, the other seeks institutional funds; one makes loans, the other equity investments.
Vittana, a Seattle-based nonprofit organization founded in 2008, raises loans for students in Mongolia, Nicaragua, Paraguay, Peru, and Vietnam[iv] through online, peer-to-peer lending. Peer-to-peer (person-to-person) lending allows individuals, mostly from wealthy countries, to identify college students to whom they would like to make a loan and then effortlessly arrange a transfer of funds.
Lenders give Vitttana $25 or more to fund a particular student. Once the total from all donations for that student are sufficient to cover his or her educational expenses (average: $655), the funds are released. Vittana sends money to microfinance institutions in the countries it funds which give the money to funded students.
Though Vittana is just a few years old, it has received more than a half million dollars from lenders in 30 countries, and it is growing at over 30% a month.[v] What accounts for its success to date?
Vittana targets high-achieving students. Vittana’s microfinance partners screen loan applicants on the basis of students’ academic records.
The screening makes sure the student loan is for enrollment in a program where the prospects for employment after gradation are good.
Vittana reduces the risk of making loans to students who never complete their education by only funding those in a twelve month or shorter vocational program or who are in their last twelve months of college. Students with more than twelve months of school remaining are less likely to complete their education.
- Vittana highlights “high-achieving, deserving” students on its website in the hope that visitors might be inspired to help out.[vi] Its search engine allows a lender in Lima, Ohio, to find someone and easily invest in someone they want to support in Lima, Peru. This peer-to-peer model might reach millions (billions?) of potential small- scale lenders interested in supporting students in the developing world.
- Vittana seeks to mitigate risk from students not repaying their loans in several ways: by making loans to the children of microloan borrowers with good credit backgrounds; by having students’ mothers or other close relatives co-sign for the loan; and by instituting a year long interest-only “grace” period after the student graduates from his or her program.
By funding only the “last mile” of students’ education and identifying candidates whose employment prospects are bright, Vittana achieves a 95% loan repayment rate. Its graduates make, on average, two to three times their previous incomes.
Finding successful and efficient MFIs is crucial for Vittana to gain scale and fine-tune the loan product to specific regional circumstances. MFIs are fully responsible for marketing the loan, finding suitable borrowers and managing the customer relationship. Moreover, Vittana conducts random audits of their partners to ensure that individual lenders’ money is well spent.[vii]
To cover the costs of developing and administering their student loan programs, Vittana’s microfinance partners charge students minimal interest, typically 10-15 percent per year. They receive no funding from Vittana, and every dollar that Vittana sends from lenders goes towards students’ education. Neither Vittana nor the initial peer lender charges interest, and peer lenders are repaid when students repay their loans.
Vittana recently made a 2010 Clinton Global Initiative commitment, Vittana/Africa: Bringing Student Loans to Africa. Vittana, in partnership with leading microfinance institutions, will fund African students’ post-secondary education, aiming to fund the last of mile of the education of 10,000 students by 2015. Students will gain employable skills in fields including nursing, law enforcement, and IT.[viii]
Lumni is an international company that helps finance the college education of poor students. Operating in Chile, Columbia, Mexico, and the United States, Lumni creates and manages social- investment funds that allow low-income students to pay for college and its funders to receive financial (and societal) returns.
Lumni attracts capital from foundations, funding agencies including the Inter-American Development Bank, and wealthy individuals. It uses this money to fund a portion of a student’s college tuition and fees, but not all. In exchange, each student commits to pay a fixed percentage of his or her income for 120 months after graduation. The percentage varies from student to student based upon a number of factors including the student’s grades, job, the amount of funding received from Lumni, and the amount of funding from other sources.
The Lumni model shifts risks from students to investors. Students earning more money after they graduate repay more every month (remember: repayment is based on a fixed percentage applied to a student’s income), and loan repayment amounts will rise, too, as a student earns more over time. A typical situation is a student who receives $16,000 over four years from Lumni and repays at 4-8 percent of his or her income after graduation. This is approximately equal to repayment of the principal at an 8.5 percent annual interest rate. The student’s obligation is complete at the end of 120 months, even if his or her total repayment is less than the amount s/he received. Lumni also allows students to work in activities like the Peace Corps without worrying about repayment. Under this design, students face little risk of overly burdensome debt payments, providing peace of mind for debt-averse populations that are most in need of funding.
Investors are repaid, with interest, which essentially makes their financing of students’ education an equity investment: The more students earn after graduation, the greater the investors’ financial return.
For its part, Lumni offers career coaching, networking, and technical support to students after graduation. Lumni receives a fee for raising and managing the fund.
Lumni has raised and obtained commitments of more than $15 million from more than 100 investors. Lumni has financed nearly 2,000 students to date, nearly all from low or very low-income backgrounds where funding recipients are the first family members to attend college.[ix] In addition to the dual financial and social return from their investment, contributors are helping prove an efficient, sustainable new system for giving students access to college without the burden of a traditional student loan.[x]
Parvati Patil, a Masters in Public Policy graduate from the University of Michigan, brought these ideas to my attention and did the initial research for this paper. She and I both contributed to this post. Her blog is available at http://tenmarks.wordpress.com/
[i] UNESCO, Education For All Global Monitoring Report, 2009 http://www.unesco.org/new/en/education/themes/leading-the- international-agenda/efareport/reports/2009-governance/ (accessed on December 11, 2010)
[ii] John Hatch, Expanding Microcredit Services to Young Adults: Research Findings, Rationale, Blind Spots, and Recommendations, 2004
[iii] Alain de Janvry and Elisabeth Sadoulet, Conditional Cash Transfer Programs: Are They Really Magic Bullets?, 2004 http://are.berkeley.edu/~sadoulet/papers/ARE- CCTPrograms.pdf (accessed on December 11, 2010)
[iv] FAQ Vittana, http://www.vittana.org/faq (accessed on December 8, 2010)
[v] Making the Grade, Economist, http://www.economist.com/node/16996791 (accessed on December 8, 2010)
[vi] Huffington Post http://www.huffingtonpost.com/2009/10/29/huffpost-game- changers- whn337128.html?slidenumber=G6ny07MYCRM%3D&slideshow#s lide_image (accessed on December 8, 2010)
[vii] Next Billion, http://www.nextbillion.net/blog/2009/11/20/vittana- student-loans-and-a-new-generation-of-microfinance (accessed on December 12, 2010)
[viii] Organizational Partners http://www.vittana.org/partners (accessed on December 11, 2010)
[ix] About Us, Lumni http://lumni.net/forpotentialinvestors/ (accessed on December 8, 2010)
[x] Lumni, http://lumni.net/forpotentialinvestors/ (accessed on December 8, 2010)
How can we make sense of all the changes taking place around us? More importantly, how can we create the change necessary to attack our most pressing societal problems?
Short answer: building blocks. I will return to this theme again and again in other posts. But for now: a preview.
Eric Beinhocker's Origin of Wealth leans on the theory of complex systems to show how, little by little, a small thing like a wheel gets incorporated into increasingly complex components and systems. First we see carts, then bikes, then the Audobon. More building blocks mean more complex combinations built from them. And these combinations give rise to greater variety, greater sophistication, and greater wealth.
Brian Arthur's The Nature of Technology provides a related account, up to a point, but emphasizes how change is not always gradual and continuous. For instance, piston-powered propeller airplanes began as rather simple machines and performed well for short flights. But when these planes began to fly at higher speeds at higher altitudes, their limitations became evident. To address them, engineers began making a series of increasingly complicated modifications until, finally, an entirely new means of powering a plane appeared: the first jet-engine. This invention was not further evolution of the piston-propeller arrangement but, instead, was based on entirely different principles. It was much simpler too, the original prototype of the jet engine having just one moving part!
In my book, Design Your Life, Change the World: Your Path as a Social Entrepreneur, I have examined how similar ideas apply to social enterprises. Often, social enterprises evolve gradually, becoming increasingly effective as they become ever more complex. As an illustration: Once, local banks were as much fixtures of communities as mom and pop grocery stores (been to one of those recently?). Over time, they began to add remote branches and, as regulation allowed, expanded their reach to increasingly distant locales. These changes were intended to create more efficiency, more competition, and more choice.
Overseas, a similar evolution began to include poorer and poorer customers as first, nonprofit organizations and later, for-profit banks began to offer microcredit and other microfinance offerings. Still, microfinance excludes ten times as many customers as it serves. Poor clients are expensive to serve, even more so when they are at a distance. Branches are too expensive in many parts of the world.
Yet in Kenya, an invention has dramatically changed the situation. Much like the jet-engine, which overcame the deficiencies of propeller planes by incorporating a completely new principle, M-Pesa overcame financial exclusion, especially created by distance, by creating an alternative form of money. Kenyans buy this currency, which is installed on their cell phones. This e-currency can then be safely, conveniently, and affordably transferred to someone else by sending a financially secure text message. Urban workers can remit money to relatives in the countryside. Micro-entrepreneurs can buy trinkets or agricultural products to resell without the insecurity of relying on bus drivers to transport their payments or the inconvenience of taking the bus to make payments themselves.
How successful is M-Pesa? Over half of all Kenyans use it, nearly three times as many as have bank accounts. M-Pesa has created similar services in Tanzania, Afghanistan, and South Africa. It recently created a partnership with Western Union that allows funds transfers to Kenyan M-Pesa customers from 45 countries.
Is this a "one-off," relevant only to citizens without ready access to banking services? Not at all. Mobile wallets (as they are known) are moving "up market" to the United States and the rest of the developed world. Tech stalwarts (Apple, Google, and others), mobile carriers (including Deutsche Telecom, China Unicom, Verizon), and financial institutions and credit card companies (among them Chase and Visa) are all exploring how they can capture this huge, potential market.
What was created by the invention of alternative currency has begun to evolve.
Let's consider this illustration from an evolutionary perspective.
The banking system changed in ways that resemble biological evolution. New variations (say, bank branches) are tested for their performance (would people use them?) and, when successful, they proliferate.
Producing societal-level change isn't under the control of any single organization. Consider the environment. No company or government, of course, "controls" efforts to address climate change. Yet there are many ways organizations play roles in striving to stem our environmental problems.
How can we stack the odds so that they are successful?
By encouraging variation, creating fair and effective tests, and ensuring that winning ideas truly proliferate. These are not abstract ideas without application. For instance, the tests performed in the marketplace (profit, sales) give distorted results that fail to account for environmental (mis-)behavior. As the adage goes, you get what you measure, and we are measuring the wrong things. Similarly, proliferation can come from replication, but exposing winning ideas to others provides another means to increase their scale.
But we must be cognizant, too, that invention is sometimes necessary to spark progress when we are at an impasse. Methods like recycling, just like propeller-powered planes, can't evolve far enough to achieve our environmental ambitions. Recycling is better than tossing, but as a practice it still fails to promote better, inherently green methods of creating products in the first place. That is where invention becomes critical, to create "jumps" in evolution rather smooth, gradual refinements. Markets in carbon avoidance, for instance, are built on the premise that you can buy the benefits of others' good behavior. From this new premise various ways to create and operate these markets emerge, themselves subject to variation, testing, and proliferation. Invention begets evolution.
These two forms of change - gradual, continuous; and radical; discontinuous - operate by creating and re-organizing building blocks. We can think of building blocks as fundamental elements that underlie the process of creating change. To be architects of change, we must learn to recognize and harness them. I intend this blog entry itself to be a conceptual building block which we return to, and build on, as we understand how to improve society.
Those of us who seek societal change have to think about how we can create impact. As an educator, I have the opportunity to share my ideas with students, who can think about them, modify them to suit their needs, and apply them to problems they are attacking. That source of impact is my privilege.
Erica Anzalone-Newman was student in a course I teach on "Solving
Society's Problems through Innovation and Enterprise." In the essay
that follows, she beautifully illustrates key themes from the my book, Design Your Life, Change the World: Your Path as a Social Entrepreneur. These themes are:
- Big Picture Design. First, design everything:make sure that you consider everything in your design thinking, not just the central product or service you're providing. Among other features, these would likely include how you distribute your product, gain acceptance for it, and make it affordable. And second, steal shamelessly: attempt to identify ideas with proven merit and use them for the problem you're addressing.
- Make It Appropriate. Ensure that your product or service not only is relevant -- but is also perceived as being relevant -- to the context in which you are working.
- Make It Stick. Make sure that you have the means to successfully introduce a product or service to a new region and that you can "embed" it so that it gains long-term acceptance.
Make It Bigger. Find ways to spread you product or service to other regions so that it benefits more people. Also, you can increase awareness of your ideas or recruit others to join you so that your idea is taken up and spread.
Learning from Brazil's Assault on HIV/AIDS: Applications in US Urban Communities
by Erica Anzalone-Newman
Examples of transplanting modified, developed-world innovations to the developing world are rampant. Yet there is much to be gained by organizations serving US populations adopting and adapting business and service delivery models developed in developing countries. More specifically, Brazilian groups have developed and executed one of the most successful responses to HIV and AIDS in the developing world, if not the world at large. The Brazilian response to HIV/AIDS is based on component elements that might be modified for implementation in US urban centers, including Newark, NJ.
Before I explain how that can occur, I present a brief history of the spread of HIV/AIDS in both
locales. HIV/AIDS in Newark, NJ: History and Context Newark has a long history of a high incidence of HIV/AIDS cases, wrought by the virus essentially since its first detection in 1981. The context for Newark's AIDS crisis began with the infamous race riots of 1967, after which the population declined significantly and many businesses left the city. Employment rates plunged, and the poverty rate soared. By the late 1980s, one-third of the residents lived below the poverty line, and homelessness was three times that in New York City .
As the city lost the vast majority of its middle-class, an "underground" economy began to thrive , and Newark became plagued by political corruption, insidious crime and, importantly, pervasive drug use. According to a New York Times article written at the height of the AIDS epidemic, "[New Jersey] stands apart as the first state in which intravenous drug abusers, rather than homosexuals, make up the largest group of victims." 
This was especially true in Newark, New Jersey's largest city. Indirect effects of intravenous drug use were that women, with virtually no job prospects, turned to prostitution to support addictions, increasing exposure to and the spread of HIV . Drug-addicted men, as well as those engaging in sex with prostitutes, were similarly exposed; in turn, they began to infect non-drug using wives and other sexual partners, who were often unaware that they were infected until their newborns were found to be HIV-positive at birth. According to one Coordinator from the U.S. Centers for Disease Control, "'In cities like Newark, AIDS [had quickly] become a disease of the family" . By early 1989, there were nearly 1,200 cases of AIDS in Newark, of which more than half resulted in death . Clinical research was fairly prominent in Newark; however, community-based efforts, such as outreach, prevention, treatment and care were minimal .
HIV/AIDS in Brazil: History and Context
The first case of AIDS in Brazil was recorded in 1982 . In the early years of the epidemic, the majority of HIV carriers and AIDS victims were men who have sex with men in large urban centers. Other populations initially affected in disproportionate numbers included intravenous drug users and individuals requiring blood transfusions . However, since 1993, heterosexual transmission has been most prominent . During the early- to mid-1980s, as Brazil was realizing true democracy for the first time, NGOs were instrumental change agents within Brazilian society. These groups were vocal proponents of government intervention on a variety of fronts, including HIV/AIDS prevention and treatment. They were also instrumental in encouraging "a climate of social solidarity, allowing open and frank debate about HIV and AIDS." . The responsiveness of the government, inspired by the pressure imposed and partnerships formed by NGOs, has been central in stemming the spread of HIV/AIDS in Brazil.
A Critical Look at the Brazilian Approach to Combating HIV/AIDS
- Big Picture Design and Making It Bigger
Based on the spread of HIV in Brazil through the early 1990s, World Bank estimates indicated that 1.2 million Brazilians would carry HIV by 2000; instead, the true figure was only six hundred thousand, and HIV growth since 2000 has been slower than in many other nations, as well .
It seems that adherence to the tenets of Big Picture Design and emphasis on growing efforts to scale have been central to this relative success story. Certainly there were numerous elements of the Brazilian approach that were grassroots in nature (i.e. not developed as part of a master "Big Picture Design" plan); still, the approach is impressively comprehensive in terms of the demographic and geographic segments it covers; the attentiveness to all aspects of product and information dissemination - including the underlying tone or message accompanying each individual initiative; the combination of top-down and bottom-up
initiatives; and the efforts aimed at both prevention and treatment.
NGOs started the conversation about HIV in Brazil, but quickly sought government involvement to set the tone for addressing the virus nationwide. The government first undertook distribution of information, to raise awareness and educate on prevention, with a focus on the highest-risk groups within the population .
In 1988, the country's new constitution included legal protection against discrimination for people living with HIV, as well as free access to healthcare for all Brazilians. Healthcare for all included the provision of free antiretroviral drugs (ARVs) to people living with HIV; by 2007, 80% of those requiring ARVs were receiving them . Availability of ARVs drastically improved AIDS-related mortality rates and also reduced the number of mother-to-child transmissions.
The government has also promoted growth within the Brazilian pharmaceutical industry, which is now equipped to produce 40% of AIDS drugs domestically; this increases the long-term viability of free distribution to citizens, as it enables the government to purchase ARVs at lower prices those drugs that must be produced internationally, the government has put significant pressure on foreign pharmaceutical firms, threatening the issuance of "compulsory licenses" to elicit lower prices. "Compulsory licenses allow countries to override patent laws and produce their own generic (copied) versions of company-owned drugs, and can be issued when the government of a developing country deems it to be a public health emergency." 
In 2007, the Brazilian government actually issued a compulsory license for an AIDS drug produced by Merck. This action has had an impact beyond lower ARV prices; it demonstrates the government's willingness to provide bold support for HIV/AIDS initiatives even in the face of harsh criticism.
These are just a few examples that illustrate the collaborative "passing of the baton" back and forth, between the Brazilian government (top-down) and NGOs (bottom-up), which has contributed to Big Picture Design in that the Brazilian approach has the necessary scope and scale to be effective.
These examples also illustrate the notion of "designing everything." For instance, it is not enough to make HIV testing available; you must also provide resources, so that people are not deterred by their inabilities to respond to the test results, financially or otherwise. Finally, these examples speak to the complementarity between prevention and treatment efforts, which could only be discovered through careful analysis of the "Big Picture": the virus's entire life cycle.
- Making It Appropriate
The Brazilian approach involves a supreme focus on being relevant and perceived as relevant. For example, media campaigns for testing have featured celebrity advocates, who tend to be especially influential among youth, and prevention campaigns use all types of media, including TV, newspapers, billboards, bus shelters, and others . Much HIV-prevention work is based on condom distribution, with particular emphasis on settings and geographies in which condoms are most absent. For example, during the 2009 carnival season, 65 million condoms were distributed - an increase of 45% over the usual number distributed in an average month - because carnival season tends to be correlated with increased sexual activity in Brazil . Condom distribution and other forms of grassroots education and support have also been especially prominent for sex workers, as prostitution is legal in Brazil, and sex workers are at high risk for both contracting and transmitting HIV .
There are other examples of "making it appropriate," too. There is an emphasis on preventing HIV-positive mothers from breastfeeding, by providing both education and breast milk alternatives. Additionally, rapid HIV tests are widely available in maternity wards. Needle exchange programs for intravenous drug users are widespread, as is counseling and access to treatment targeted at this group. In "shanty towns," NGOs have fostered peer-to-peer education networks by training youth representatives .
The Brazilian approach involves being present at absolutely every touch point in an individual's life when HIV could potentially be transmitted, and providing information and products through channels that are familiar and disarming.
- Making It Stick
The paramount explanation for why the fight against HIV/AIDS is so embedded in communities within Brazil is the work that has been done to de-stigmatize and de-politicize the virus. From the outset, NGOs pushed the government to approach the need for HIV/AIDS prevention and treatment as a human rights issue, not a moral or religious issue, or one that impacts only certain minority groups withinthe country . "The Brazilian response has... pushed for everyone - from the President to prostitutes - to practice safe sex. Public health experts say Brazil's approach works because it doesn't discriminate" - just like the virus . Brazil's fight against stigma, as well as its "tolerant, non-judgmental approach to HIV prevention," are considered unique differentiators in the fight against AIDS .
Potential Applications in Newark, NJ
It is reasonable and realistic to acknowledge that certain Brazilian programs, particularly some of the governmental programs, are not precisely replicable in the US due to fairly different social mores; some Americans may raise moral objections to some of the Brazilian methodologies. Ultimately, however, Brazil's success vis-à-vis the de-politicization of responding to HIV/AIDS, is too great to ignore. (Recall: Big Picture Design advocates "stealing shamelessly.") Perhaps the only way to respond to HIV/AIDS so comprehensively within the US is to shift the majority of the load to private organizations, rather than relying on government intervention to the degree that Brazilians did. (Making ItAppropriate means seeking relevance through flexibility, not rigidly applying an approach that will be unwelcome and rejected.)
One opportunity area involves modifying the Brazilian model for partnering with sex workers, to partner with intravenous drug users in Newark instead. These two populations are approximately the same in their respective locales in terms of bearing disproportionate risk of carrying and transmitting HIV. There have been some recent needle exchange efforts in Newark, but there is also a long history of NJ state government opposition to such programs. Needle exchanges have consistently correlated with reduced spread of HIV in pilot areas, and given the direct and indirect contact that drug users have with other segments of the Newark community, this would seem to be a worthwhile early investment.
Perhaps a new enterprise is needed for this to be feasible: a syringe manufacturer that sells syringes to local doctors' offices, hospitals, and clinics in order to subsidize the costs associated with needle exchange programs. This enterprise could even arise as a subsidiary of one of NJ's many pharmaceutical and medical supply producers. To be most relevant, needle exchanges would need to be most prominent around the first of each month, when welfare checks are distributed and spending on drugs is highest in Newark.
Another opportunity area involves replicating Brazil's myriad campaigns to reduce the stigma associated with HIV/AIDS,as this has historically been a severe problem within the predominantlyblack and Latino communities in Newark. The subject matter of the campaigns could run the gamut from human rights-themed messages, to celebrity (local or national) endorsements of HIV testing, to educational public health messages that inform/remind people about how HIV is transmitted.
While there are surely a number of other specific applications of the Brazilian strategy for Newark, generally speaking, Newark should focus on a few thematic lessons from the Brazilian case: First, Newark organizations should learn from the Brazilian concentration on being relevant and relentless at every touch point in individuals' lives at which they might be exposed to HIV; action at manyof the aforementioned touch points in the Brazilian context would be directly transferrable to the Newark context. Second, Newark organizations should recognize the importance of making AIDS a sustained, public conversation about a public health issue - whether that is done with or without the government's assistance. Finally, Newark health organizations (e.g. hospitals and clinics) and/or the local government should focus on identifying incentives for private sector producers of products that are needed for prevention and treatment efforts, in order to procure these products at manageable prices.
 Williams, L. (1989, February 2). Inner city under siege: fighting AIDS in Newark. The New York Times. Retrieved 13 Nov, 2010, from http://www.nytimes.com.
 Tierney, J. (1990, December 16). Urban Epidemic: addicts and AIDS - A Special Report: in Newark, a spiral of drugs and AIDS. The New York Times. Retrieved 13 Nov, 2010, from http://www.nytimes.com
 Narvaez, A. A. (1987, July 21). Newark hospitals seek unit for AIDS treatment. The New York Times. Retrieved 13 Nov, 2010, from http://www.nytimes.com
 Tierney, J.
 Williams, L.
 House of Representatives Committee on Governmental Operations. (1990). "The AIDS Epidemic in Newark and Detroit." Washington, DC: U. S. Government Printing Office. Page 50.
 Ibid, page 35.
 http://www.avert.org/aids-brazil.htm Accessed 14 Nov. 2010.
 Bacon, Pecoraro, et al. "HIV/AIDS in Brazil." UCSF Country AIDS Policy Analysis Project. San Francisco (2004): 9.
 http://www.avert.org/aids-brazil.htm Accessed 14 Nov. 2010.
 The Economist. (10 May 2007). "Brazil's AIDS Programme: A Conflict of Goals." Sao Paolo. Retrieved 13 Nov, 2010, from www.economist.com
 http://www.avert.org/aids-brazil.htm Accessed 14 Nov. 2010. 14 Ibid.
 Public Radio International. (11 Jan 2010). "Brazil's Effective HIV Prev
ention Strategies." Accessed 13 Nov, 2010, from www.pri.org
 http://www.avert.org/aids-brazil.htm Accessed 14 Nov. 2010.
 Ibid. 20 Ibid.
 Public Radio International. (11 Jan 2010). "Brazil's Effective HIV Prevention Strategies." Accessed 13 Nov, 2010, from www.pri.org
 http://www.avert.org/aids-brazil.htm Accessed 14 Nov. 2010
My daughter graduated from Oberlin College on Memorial Day. The ceremony took place in a park with little shade on a crystal clear day, the kind you get in the Midwest when the temperature spikes 40 degrees in twenty-four hours. It was sweltering.
But the true intensity came from the anticipation of what lies ahead, measured in people to be helped, a planet to be saved, lives to be changed.
Of course, the template for graduation speeches is to remind students to remember friends and institution; follow their dreams; and give back to others.
But Oberlin is different. A liberal arts college and music conservatory founded in 1833 in Oberlin, Ohio, it admitted women from the beginning, and granted women the first bachelor's degrees in the country in 1841. In 1835, it became the first college to adopt a policy to admit students regardless of race.
The town has long had progressive roots as well. It was a pivotal stop on the Underground Railroad that ushered slaves to freedom in the north. Residents' of Oberlin and the neighboring town of Wellington efforts in helping a fugitive slave flee to Canada reportedly sparked the Civil War.
Today, Oberlin and its environmental visionary, Professor David Orr, are in the early stages of creating a carbon-neutral, economically vibrant community that brings together town and gown, farm and city, today's needs and tomorrow's demands. The Oberlin Project is a beacon pointing to the kind of world we can create if we try.
So, there was a rich and storied context as Oberlin's commencement speaker, Dr. Helene D Gayle, spoke about changing the world.
Dr. Gayle had planned to be a pediatrician but had an epiphany at her brother's college graduation, where an epidemiologist described a successful campaign to eradicate smallpox. The speech allowed Gayle to see how her own skills in medicine could be more broadly applied in a career in public health, providing her the opportunity to address interlinked problems of poverty, lack of affordable health care, and a broad set of inequities throughout the world.
Thus was launched her remarkable career, first with the Centers for Disease Control and Prevention where her efforts focused on HIV/AIDS; then at the Gates Foundation, where she directed the foundation's HIV, TB and Reproductive Health program; and now at CARE (one of the best known organizations in the world devoted to fighting poverty, supporting women, and bringing about social justice), where she has been President and CEO since 2006.
All because she was moved by a commencement address.
Some Oberlin graduates undoubtedly were moved by Dr. Gayle's remarks, their futures shifted in positive ways that will be revealed over the course of their lifetimes. And yet others - including those who want to make a difference in the world - are still searching, despite the glimpse of all things sustainable, equitable, and right about the world that four years at Oberlin exposed them to. I know, because I asked. And because I teach students who are also looking to create meaning in their lives.
As a professor at the Ross School of Business I teach courses with titles that are a bit too long, like Solving Societal Problems through Innovation and Enterprise. In these courses, I want my students to see that innovation can propel for-profit and nonprofit organizations to tackle some of the world's chief challenges: poverty, health care, education, the environment. And taking these problems on can be done from a sense of opportunity, not just responsibility.
We discuss ways to dramatically improve health care with cell phones, discarded medicines, and video games. We consider improving education for children in India with "educational Karaoke," teenagers in the worst Bronx schools by training them as entrepreneurs, and college-ready students in Arica who cannot afford tuition by providing free, world-class college curricula. We discuss charities run as for-profits, multinational corporations working in full-partnership with slum dwellers, alliances between environmental NGOs and huge retailers who intimately depend on each other for their mutual success through saving the rainforests, and powerful means of harnessing the power of collective action to identify, solve, and accelerate solutions to the world's most pressing challenges.
Why do students flock to these courses? Because they hunger to combine their intellect and their hearts. They crave the sense of meaning that comes from creating, especially when they find work that provides them with a means of support and a vehicle to have huge impact. And mostly because they see the world with fresh eyes, free from the cynicism that that can come from thinking that anything that can be tried, has been tried.
The companies and organizations that are forging a better world need fresh eyes, too. The practices that have gotten where we are - a physical planet in perilous shape and a socio-economic planet where the distribution of wealth and access to life's necessities (let alone luxuries) is more skewed than ever before in history in favor of the "haves" - are not the same practices that can lead us to a planet capable of sustaining us physically or providing a secure, healthy world that truly creates opportunity for all.
Graduation is both an end and a beginning. It is a time to reflect, give thanks, and seek renewal.
To my daughter Hannah I say,
"Congratulations on completing your degree. I'm so proud of you. As you take your Oberlin degree into the world, I know we are lucky to have you joining the fight for a more sustainable world. Lead, take action, and become a life-long student." (The word "student," derived from Latin, suggests study, scholarship, and learning - not necessarily formal education, you know.)
And to students everywhere - whether you're enrolled in a degree program; striking out on your own as a (social) entrepreneur; working in an organization; or possibly running one - I say,
"There's never been a time we've more urgently needed new ways of addressing the societal issues in front of us. There are innovative ways for business to seek opportunity to serve, rather than acting purely with greed, frustrating progress, or withholding their formidable talents that could be used to create immeasurable benefits. It's time to see the world with fresh eyes and create a better world. It's time for us to graduate from old ways, which no longer serve us, and look at the world anew."
I have had the privilege to teach and learn from "students" of all stripes who want a more just society: those enrolled in my classes of course; but also those who I've worked with and supported on the ground in inner cities and the farthest corners of the planet; officials of organizations devoted to a more equitable society, whether they occupy corner offices or cramped quarters in an attic; and like-minded do-ers seeking to make inroads against injustice through the provision of clean water, access to microfinance, more sustainable food systems, the elimination of homelessness, to name a few areas.
I invite you to join me in exploring a new world where we solve societal problems through innovation and enterprise. Let us learn together.