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Unusual post today: short thoughts and some shout outs. 

Who's going to save the world -- Wal-Mart or the social entrepreneur toiling away with little fanfare?

Let's consider:

Wal-Mart, the world's largest company, sells slightly more than $400 billion a year.  The poorest two-thirds of the planet -- people living $4 a day or less -- spend about ten times that amount.

Each year, Wal-Mart serves 100-200 million customers.  At most, that's less than 3% of the world's population.

Wal-Mart's recent shift from focusing exclusively on everyday low prices to finding profit in acting in pro-social ways has been commendable.  It has committed to creating zero waste and obtaining all its energy from renewable sources.  It announced this week that it will open 300 stores to bring fresh food to inner-city "food deserts" in the next five years (on top of the more than 200 it already operates).  It has entered the low-income banking business in Latin America and, in the U.S., where it can't officially run a bank, it works through partners to offer unbanked Americans low-cost money orders, check cashing, and overseas remittances.

Despite Wal-Mart's heft and new found focus on creating business opportunities from addressing societal ills, it can't meet many of the most basic requirements of the needy. 

In the developing world, access to clean water is arguably the most fundamental need of the poor.  Protection against preventable diseases, including malaria and diarrhea, is close behind.  These are beyond the ambit of Wal-Mart's merchandising. 

Even Hindustan Unilever, with its more targeted efforts to address the needs of the poor, has been unable to respond effectively enough to these needs.  With revenue one percent of Wal-Mart's, Hindustan Unilever does reach deep into Indian rural life through efforts such as its Project Shakti, which creates door-to-door selling opportunities for poor, rural women. (Have you heard of Avon Ladies?)  It recently announced an altruistic effort to study the under-supply of water, and has made previous efforts to help renovate village ponds, manage watersheds, and promote improved water harvesting.  Despite these efforts, clean water remains in short supply, with more than 750,000 deaths occurring each year in India alone from water contamination.   

In the United States, basic needs are under-served, too.  Despite (or motivating) Wal-Mart's food efforts, food deserts exists throughout the country.  (See the USDA's interactive map.)  The consequences?  Poor people eating less nutritious, usually fattening food, or inconvenient and costly (in time and money) travel to obtain food of higher quality.  Likely, too: a higher incidence of serious illnesses and premature death.

Nor is the financial services picture rosy for the U.S. poor.  The FDIC estimates that over one-fourth of all households, accounting for 60 million adults, are unbanked or underbanked.  For blacks and Hispanics, the proportion is approximately 50 percent.  The alternative financial services that these un- and underbanked use -- non-bank money orders and check cashing, payday loans, pawn shops, and others -- are necessary, but costly, ways to live without formal banking.

So, where do social entrepreneurs come in?

Social entrepreneurs provide services where companies are absent, where they don't sell the right products, or where they sell products that are simply too expensive.

Social entrepreneurs (or non-profits) together with companies form a co-adaptive ecosystem.  What companies leave unattended -- in their "background" -- creates the foreground environment for social enterprises, shaping their opportunities .  In turn, social enterprises can serve as a type of free, and early, testing ground for companies.  The success of non-profit microfinance institutions in providing banking services for the poor, for instance, caught the notice of larger, for-profit banks, spurring their entry into the same market.

As social entrepreneurs prove successful in reaching their constituents, for-profit companies take notice.  And, as companies change their focus, they affect social entrepreneurs.  This interplay has led nonprofit microfinance institutions to serve poorer, more rural customers as larger, for-profit providers use capital markets to offer more, and larger, loans to wealthier segments of the poor.

Today, we are seeing examples overseas of early-market activity among social enterprises in the field of water:  Naandi (water purification and delivery), Wello (water transport and business opportunity), and Sarvajal (a filtration and franchising model). 

In the U.S., healthful food is offered to the poor through a variety different kinds of social enterprises.  D.C. Central is a community kitchen that not only "recovers" and delivers good food headed for waste, but trains low-income individuals for jobs in the food services industry.   Peaches and Greens, a mobile produce market, makes scheduled delivery stops and home-deliveries in inner-city Detroit three seasons a year.  And even urban farming is proving viable, as organizations such as Growing Power, headquartered in Milwaukee, are proving. 

It waits to be seen whether such efforts in water and healthful food will one day be viewed as attractive opportunities for many large companies.

----

So, who's going to save the world -- mega-corporations like Wal-Mart with their size, reach, and efficiency; or social entrepreneurs, who can attack deeply entrenched problems without a slavish focus on bottom-line results?

My answer: both -- by acting and adapting in response to each other even as they continue to do what they do best.

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 [1].


As the city lost the vast majority of its middle-class, an "underground" economy began to thrive [2], 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." [3]



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 [4]. 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" [5]. By early 1989, there were nearly 1,200 cases of AIDS in Newark, of which more than half resulted in death [6]. Clinical research was fairly prominent in Newark; however, community-based efforts, such as outreach, prevention, treatment and care were minimal [7]. 

HIV/AIDS in Brazil: History and Context The first case of AIDS in Brazil was recorded in 1982 [8]. 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 [9]. However, since 1993, heterosexual transmission has been most prominent [10]. 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." [11]. 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 [12]. 

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 [13].


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 [14]. 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." [17]

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 [18]. 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 [19]. 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 [20]. 



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 [21].



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 [22]. "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 [23]. 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 [24].

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. 




[1] 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.


[2] 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 


[3] 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


[4] Tierney, J.


[5] Williams, L. 


[6] House of Representatives Committee on Governmental Operations. (1990). "The AIDS Epidemic in Newark and Detroit." Washington, DC: U. S. 

Government Printing Office. Page 50.


[7] Ibid, page 35.


[8] http://www.avert.org/aids-brazil.htm Accessed 14 Nov. 2010.


[9] Ibid.


[10] Bacon, Pecoraro, et al. "HIV/AIDS in Brazil." UCSF Country AIDS Policy Analysis Project. San Francisco (2004): 9.


[11] http://www.avert.org/aids-brazil.htm Accessed 14 Nov. 2010.


[12] The Economist. (10 May 2007). "Brazil's AIDS Programme: A Conflict of Goals." Sao Paolo. Retrieved 13 Nov, 2010, from www.economist.com


[13] http://www.avert.org/aids-brazil.htm Accessed 14 Nov. 2010.
¹⁴ Ibid.


[15] Public Radio International. (11 Jan 2010). "Brazil's Effective HIV Prev

ention Strategies." Accessed 13 Nov, 2010, from www.pri.org


[16] http://www.avert.org/aids-brazil.htm Accessed 14 Nov. 2010.


[17] Ibid.


[18] Ibid.


[19] Ibid.
 ²⁰ Ibid.


[21] Ibid.


[22] Ibid.


[23] Public Radio International. (11 Jan 2010). "Brazil's Effective HIV Prevention Strategies." Accessed 13 Nov, 2010, from www.pri.org


[24] 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.