Hacktivate

Challenges

Bringing technology into health clinics can benefit healthcare workers, patients and public health workers with improved decision making support and better quality data. While there are many benefits offered by a successful system, there are many challenges in creating and sustaining a successful implementation. This document will discuss the problems of electricity, viruses, repurposing of equipment, theft and will also discuss solutions for these problems.

Electricity

Even in developed countries electricity is unreliable. Equipment wears out, the infrastructure is overburdened, lightning strikes, people forget to pay their electricity bill. In developing countries like the Philippines, particularly in rural environments, the problems are amplified. Instead of power outages occurring just a few times a year and lasting 5-10 minutes, developing countries experience monthly or weekly power cuts lasting for hours at a time. The approaches used by developed countries for handling their relatively short, infrequent power cuts work are optimized for their situation, and are hence a poor fit for developing countries. UPSs are the standard solution for desktop computers in developing countries. Their components are designed for infrequent use and are optimized for delivering 15-30 minutes worth of electricity at the power level a desktop computer requires. When these UPSs are deployed in developing countries they are unable to sustain equipment through the multi-hour power cuts and they tend to wear out very quickly due to the high frequency of use that they receive. Developing countries require a reliable power solution that is better aligned with their realities.

Viruses

Viruses are a major problem for Microsoft Windows users, which are the majority of computer users. While recent Microsoft products have improved their security models, all users of Windows are strongly recommended to use antivirus software. But for antivirus software to be effective it must be constantly updated in order to avoid being infected by the new viruses and attacks that appear daily. Because virus updates usually cost money, and require reliable internet connections, updates are often forgotten. This problem is particularly serious in developing countries. Even if money is available for updates, a reliable internet connection is often not available, so antivirus systems are often out of date.

Some virus infection techniques are also particularly effective in developing countries. Because few people have their own computer and even fewer have access to the internet, USB flash disks are used heavily. People carry their personal data on their flash disks, and then plug them into computers that are shared - either at work, an internet cafe or at friends' houses. As these disks move from computer to computer they become infected and end up attacking every computer that they are used on (which often have no or an old antivirus program). This combination of out of date virus software and heavy use of USB flash disks means that computer viruses are rampant in developing countries. Pirated movies and software which are also widely used and distributed in developing countries are another common virus spreading medium.

Repurposing

Computers are multi-functional devices. They can be used for writing reports, storing patient information, watching movies, looking up useful information and playing games. While it is great that a computer can do so much, it often means that a computer purchased for a specific project rarely stays dedicated to this project. In some cases, repurposing or multi-purposing a machine can improve the overall goals of a project. But when a machine that performs a critical function isn't available because it is being used for another purpose or is not functional due to a problem caused by another program that was installed then the project can be compromised. For a health clinic, if a computer is used for patient care and real-time recording of patient information then it is critical that the computer is always available and working reliably.

Theft

Finally, computers are easy targets for theft. They provide a lot of value in a small package. Whether an inside job or a simple break-in, a personal home or a workplace, the computers are often the first items to be stolen. Computers in rural, poverty stricken areas make for tempting targets.

Solutions

These four problems: electricity, viruses, repurposing and theft, must be carefully considered for any kind of computer based system to be successful in a developing country. Now that the problems have been described, this document is going to explore solutions to these four problems.

Electricity

Frequent multi hour power cuts require something other than UPSs. Developing countries often turn to diesel generators, which are poor choices because they require special maintenance and fuel. I saw a generator grind to a halt because no one changed the oil and I know that given the choice to keep fuel in the generator or to go rescue a sick patient with the ambulance, that the ambulance always wins. Even with a generator there will be a few second gap without electricity that will reboot all of the machines. How can we move beyond the generator paradigm?

The first and most important approach is to reduce the amount of electricity that is required for a computer to operate. Desktop computers tend to consume about 150-200 watts of electricity while they are being used. Laptop computers will consume only 10-30 watts of electricity. This means that for a laptop computer to operate it needs just a a fraction of the electricity that a desktop computer needs. Clearly laptops are a good choice when electricity is a scarce resource. The other reason that makes laptops a good choice for developing countries is that they come with an optimized battery back up system already built-in. Laptops are designed to handle frequent, multi-hour power interruptions and are hence a very good fit for the kind of situations found in developing countries. The combination of low power requirements and battery optimization means that modern laptops will run for 4-10 hours on battery power. Laptop cost has also dramatically fallen making them cost close to the same as a desktop computer. For roughly the same cost as a desktop and UPS a laptop can be purchased that will last more than 10 times longer. Electricity problem solved.

Viruses

The virus problem can be mitigated by using a non-Windows operating system and or eliminating the paths of typical infection. Ubuntu Linux is a good alternative to Windows because it is based on a very mature and proven security model that stops many of the viruses that affect Windows systems. Specifically, most activities take place within a secured sandbox that requires a password to be bypassed. Hence, viruses have a very difficult time infecting any core system processes.

Open source software is less prone to viruses than the closed source alternatives. Closed source software is distributed without access to the underlying source code (hence "closed source"). Without access to the underlying source code it is impossible for the person using it to know how the software works. This hidden layer of execution is where viruses operate. Open source software reveals everything, there is no hidden layer for viruses. While having the ability to audit software doesn't guarantee its reliability, the collaborative approach used to develop it means that malicious code rarely finds its way into open source software. Ubuntu Linux is an open source operating system and all of the additional software that most people use (like web browsers, email clients and word processors) is also open source. Practically, this means that Ubuntu Linux users have very little chance of being infected by a virus.

The other approach that can be useful is to disable flash disks, as these are the primary infection path for computers in developing countries. Of course being able to use USB disks to transfer information is an important feature, especially in developing countries, so the benefits must be weighed against the costs. There are currently no known viruses that infect Ubuntu Linux via USB disks.

Repurposing

For mission critical computer operations like the delivery of patient care, computers should be made single purpose. They should be configured so that the only function that they can perform is the function that they were purchased for. This "appliance model of computing" follows the same strategy behind household appliances like a toaster, which are dedicated to reliably performing a single task. When an appliance computer is turned on, it should immediately launch the software required for the application. The software should take up the entire screen, and the user should not be able to close the application or access a menu to launch a different application. This sort of approach will ensure that the computer is always available for the task it was purchased for. Because other programs can not be accessed or installed it means that there is no chance of the system becoming corrupted and usable because of some problem caused by another problem. This also greatly reduces the likelihood of virus infection.

Theft

Theft can be avoided by making the computers harder to physically steal, and also less desirable to steal. Physical security like strong doors/locks is obvious. Using cable locks is another important approach, although these can easily be cut by dedicated thieves. Alarmed cable locks are even better. Physically bolting machines (laptops/desktops) to desks is another good and simple strategy if you can find a good way to attach the bolt to the machine. Making a machine less desirable for theft is also a good approach. An appliance computer that is unable to play games, access the internet or a word processor is going to be less desirable for a thief who knows about the machine. Appliance computers can even be configured to operate without a hard drive, so that they will only turn on when they are in the clinic. This approach is called "net booting" and is a good strategy for reducing desirability (and also reducing system complexity as all systems will use the exact same software).

Last week I had the honor of facilitating a discussion about using technology to improve patient care at the United Nations Foundation. We had an interesting discussion, check out the writeup. Thanks to Wayan for inviting me, and to Gerry, Andrew and Gordon for coming to support me (Gerry, in particular was on fire).

[caption id="attachment_263" align="alignleft" width="453" caption="Malawian Woman Delivers Stone"][/caption]

From the Malawi Nation:

http://www.nationmw.net/newsdetail.asp?article_id=3389

Hopes of a 20-year-old Mulanje woman to have a baby turned into grief when she delivered a 300 gram stone at Mulanje District Hospital yesterday morning.
Mulanje District Health Office (DHO) and police confirmed yesterday that Agnes Msolo, in her sixth pregnancy, delivered a stone with a black string tied around it at the hospital.
Doleful looking Msolo said this is a third time she has delivered strange objects. She said last year she also delivered a stone and other strange objects.
Her voice barely audible and with a chitenje wrapped around her shoulders, the way women who deliver stillborn babies are covered, Agnes was at pains to explain her ordeal from her home in Kamoto Village, T/A Nkanda at the foot of Mulanje Mountain.
Msolo said she started feeling labour pains on Saturday and on Sunday she could not walk. She was taken to a traditional birth attendant.
“The birth attendant said she could not see the passage. She told us to go to Nkanda Health Centre [from] where we were referred to Mulanje District Hospital. I was tested, and they said the passage would soon be clear. I was given a bed, and when the doctor came to help me, out came the stone,” recalled Agnes.
In her five years of marriage, she said, she has been pregnant six times, but she has no child.
“During the first three pregnancies, I was giving stillborn babies. During the last pregnancy, I also delivered a stone and strange objects at a traditional birth attendant. We have visited traditional healers, but it has not helped. I suspect an in-law, who warned me that I was going to give birth to a stone,” said Agnes, saying she wants the case to be sorted out at Chief Kamoto’s court.
“I presented the case to the chief when my in-law told me that I was going to deliver a stone. The case was adjourned until I deliver and since I have delivered a stone, as she predicted, I want justice to be done,” said Agnes.
Her 25-year-old husband, Liston Msolo, who plies his trade as a sawyer in the mountain, said he was shocked that his wife delivered a stone again. He said he plans to divorce his wife through their marriage counsellors.
“My mother took her to the hospital on Sunday. It’s the second time this has happened. During her fifth pregnancy, she delivered a stone and some strange objects. Her relatives denied it. They blamed us, that is why we did not pursue the matter. Now, we have the evidence.
“People have always mocked me. I have visited many traditional healers, that at least I should see my child’s face but to no avail. I am afraid that if I maintain the marriage, I may die. I know there is sorcery involved,” said Liston, who dropped out of school in Standard Two.
Liston’s mother, Fanny Wilson, said they are shocked that Agnes’ relatives “do not act when we tell them of these incidences”. She said it is time her son looked for another wife.
District health officer (DHO) for Mulanje John Chikolombwe confirmed Agnes delivered at the district hospital. He said nurses at the hospital conducted manual tests on the woman since the hospital has no scanner. He said the nurses told her to go home and come back yesterday morning for a check up, only to be surprised the woman came in the night in serious labour pains.
“She was taken to labour ward where nurses were shocked when a stone weighing 300 grams with strings attached around it was being delivered instead of a baby,” said Chikolombwe.
He said he was recalled at the hospital where he conducted pregnancy tests on Msolo but no signs of pregnancy were observed.
Mulanje Police spokesman Ralphael Makondetsa said they are instituting investigations into the issue but will wait for the matter to be discussed at Chief Kamoto’s court.

Yesterday, the Cato Institute was hosting an event on the Welfare State, so Claudia and I thought it would be a good opportunity to hear some alternative viewpoints to what we have been learning in our "History of an Injustice" class.

James Bartholomew who wrote a book called, "The Welfare State We're In", was speaking. Michael Tanner from the Cato Institute (== Libertarian) was moderating and Dr. Wendell Primus, the Senior Policy Advisor on Budget and Health Issues to Speaker Nancy Pelosi (== Democrat) was there to provide an alternative view.

In many ways this was my first exposure to DC politics (even though the author was British and the book is about the UK) and really my first exposure to non-liberal thinkers in person since I started caring about social justice.

It was pretty shocking and disappointing all around.

Bartholomew struck me as a too absurd for reality cartoon character. His talk was all disjointed anecdotes about how things were better 100 years ago, and his solution is to figure out how to go back to those times. This was the killer quote from his talk:

"At the lower class level, there used to be a large number of really decent, honorable, admirable, low paid people in Britain. I don't think you would stand up in England and say that was the case now, that would be absurd." (@9:25 in the talk)

Not only does he want to eliminate any kind of unemployment and housing assistance, but he also thinks publicly funded education needs to be eliminated. His main argument for eliminating public schools was a story about a poor Welsh boy from 100 years ago who was educated by a local church charity school, read classical literature and went on to become Prime Minister. He claimed that if this boy had been bussed off to the school of today he probably wouldn't have learned how to read.

As he was saying all of this stuff I was shocked. I was disappointed in myself for not being able to remember some key statistics from my class. Bartholomew spoke about welfare as a trap that lures in the poor and they can never emerge from it, yet I recently learned that 75% of all Americans will live below the poverty line during the course of their adult lives. In other words poverty is cyclical, it is often the result of a short term circumstance (health problem, recession, divorce, etc) and it will hit most of us at some point in our lives, but we will probably emerge from it. Unfortunately I could barely remember the 75% number, and I was sadly realizing that my grasp of the class's material was less than what I needed for it to be functionally useful.

Luckily, Dr. Primus (who also worked in Clinton's administration) was speaking. I expected someone like Josh Lyman from the West Wing to passionately tear Bartholomew to pieces with rational arguments and hard data.

I was greatly disappointed. He certainly didn't agree with Bartholomew, and he wanted to talk about health care companies, but beyond that I didn't really follow much. He also used anecdotes. His were mostly about how poor people "make mistakes" and need things like health insurance.

Certainly the most intelligent speaker was Michael Tanner from Cato. Intelligent but totally out of touch. He kept speaking about how much money was spent on welfare related activities. He used real numbers, which was good, but the crux of his argument seemed to be, golly gee those numbers are high, shouldn't we care that we are spending so much money on these government programs? He didn't mention caring about the poor.

One thing was mentioned that all speakers seemed to agree on. They all had a great appreciation for the challenge of getting things done in a democracy. With these sorts of old white men standing at the front of the room I also had a great appreciation of just how hard it must be.

A few weeks ago I attended a technology salon here in DC. "The Technology Salon is an intimate, informal, and in person, discussion between information and communication technology experts and international development professionals."

Sounds cool, right? And it was. A Vodafone Foundation board member was there to talk about what Vodafone is up to in developing countries. There were a lot of smart people working in international development in DC and we had some good discussions.

The presentation from Vodafone was interesting, and it was great to see that they are aggressively building markets in developing countries. There were a few things from the presentation and discussion that I found strange, and suggested to me that service providers like Vodafone have a lot to gain from listening to international development and technology geeks. Indeed, the m-pesa idea (cellphone banking in Africa), one of Vodafone's big success stories, came from organizations working in finance in Africa.

The vast majority of projects that were discussed around the table leveraged SMS, which is not surprising since virtally all of the world's five billion cellphones can send SMS (and not MMS or email or internet). These five billion phones are an opportunity for service providers like Vodafone to grab tremendous amounts of market share. Many of the five billion phones owners have very little disposable income, but would quickly spend it on communication activities. Unfortunately, it sounds like the Vodafone strategy is to try and increase the amount of money spent by the average customer per month (currently about $5), which will translate into immediate profit, as opposed to reduce prices for SMS services which would lead to more demand, more customers, more communication and eventually more profit. Given that developing countries have by far the fastest economic growth rates, I would be establishing long term customer loyalty, so that five years from now my phone company is best positioned to take advantage of a more developed economy. Cheap SMS can do that.

Examining the cost of SMS pricing a little closer shows that it is probably the most expensive form of communication in the world, despite the cost to the service provider being almost nothing. SMS messages are attached to existing voice packets (this is where the 160 character limit comes from) and hence consume no additional bandwidth. In other words the bandwidth cost to the provider for sending SMS is zero (minus some capital costs). Why then does it cost 10 cents to send 160 characters? Sending $1 worth of data via your broadband internet connection would cost $61 million dollars to send over SMS.

Contrasting this SMS situation is Vodafone's problem with data services. They are struggling to figure out how to handle people that use their phones to download movies. Vodafone offers a fixed price for unlimited data, but a few users are spoiling the party by downloading gigabytes of data on their phones every month and squeezing the network capacity for the rest of the users.

Okay, so let's check the score. College kids are paying $50 a month for a firehose of wireless multimedia bandwidth which they use so much it is actually crippling the network. Poor farmers in Africa who need to know the price of tomatoes in the market are paying 10% of their daily earnings to send a 160 character message that costs the service provider nothing.

This is all very broken. But this is also a big opportunity for both Vodafone and people in developing countries.

The Vodafone Foundation's strategy for developed countries focuses on sports and music, while their strategy for developing countries is all about health. Setting aside the sports and music focus, I suggest that Vodafone should enable ultra low cost communication via SMS in developing countries. Maybe 1/2 a cent per SMS?

Not only would this build gigantic market share for the first cellphone provider to do it, but it would enable all sorts of value added services and projects to rise out of the villages that are in most need of new livelihoods that will lift them out of poverty and into the 21st century (and make them bigger consumers of cellphone services).

There are already a bunch of mediocre SMS based projects created and subsidized by people in places like Washington DC that are poised to do some good. What happens when we give people in developing countries the tools (and appropriate pricing) they need to solve their own problems? You get solutions. Solutions that are relevant, sustainable, innovative and worldchanging.

Imagine the future. Supertunnels through the earth's core for quick travel. Subvocal communication. 1000 year lifespans.

I feel like it has been the future this week. Some people got sick and died in Mexico and the whole world is holding its breath in trepidation. It's like everyone forgot that we were mortal and will die. I know that flu isn't supposed to kill strapping youngsters, and that we are overdue for a pandemic. And don't get me wrong I am as addicted to disaster news as the next guy, so I'm not complaining.

I'm just saying that in the future somebody getting sick and dying probably will be a major news event.

(Image by Jösé@flickr)

I am taking a course called "History of an Injustice" at the Servant Leadership School here in DC.

From the course overview:

The segregation and poverty of the American inner-city ghetto is no accident but the inevitable product of the racism of our history. From the Sundown Towns that forcibly evicted their black (and sometimes Chinese or even Jewish) residents in the late nineteenth and early twentieth century to the increasing apartheid of the twenty-first century American public school system, structural injustice has created the ghetto. In this class we'll study that history, look at some other kinds of poverty, and begin to develop a vision for a more inclusive community that might emerge from the current global economic crisis.

I have only been to one class, but so far it has been fascinating. I am really looking forward to learning about the untold stories of injustice in America.

The first assignment was to read selections from a book about Sundown Towns. Imagine Clint Eastwood telling a no good cattle rustler to get out by sundown...or else. In fact it wasn't criminals that were told to get out but minorities. And it wasn't in the gold rush days it was in the 20th century. It was shockingly common and is not particularly difficult to document, yet entirely left out of our history books.

Reno, Nevada where I grew is not listed on the author's site as a sundown town but many nearby towns are:

"A local resident who lived in Gardnerville in the 1950s describes [it]. He thought the same whistle or siren served both Minden and Gardnerville; it was probably near the border. Indians ... worked in Gardnerville, were maids, etc., but had to be out by sundown. He heard the 6PM whistle; everyone knew, white and Indian, what it was for. "Indians made themselves scarce" at 6PM. Nobody enforced it rigidly, doing anything to anyone still in town at 6:30PM. Still, "I never heard of anybody violating it." ... Gardnerville had a Chinese-run Joy Land Cafe. The Chinese didn't have to leave. No blacks in Gardnerville to his knowledge. The Chinese were friendly with the Indians, but the Indians had to eat in the back room."

(In other words in the 1950s a whistle blew every day in Minden/Gardnerville that told all of the Indians to get out of town)

"Truckee locals attempted to start a boycott against Chinese goods and laborers in their town. When many merchants continued to employ Chinese Americans, some locals turned to more direct means, such as cutting off Chinese men's braids and hanging the braids outside their houses. In June 1886, after many Chinese Americans had already left Truckee, the city fathers burned the Chinatown to the ground. Women were invited to witness the event, and fire wagons surrounded Chinatown to prevent the fire spreading to the rest of Truckee."

(Granola munching folks from Truckee of today inherit a town that was cleansed by force and fire of Chinese merchants)

I had never heard about the concept of sundown towns before reading this book. At first, I was a bit skeptical of some of his more extreme claims that so many towns across America were actually forced African Americans out. I thought perhaps he was stretching his own definition, indeed his own term, so that he could lump in more towns with the more radical ones.

My own experience told me that it was quite natural that some towns are more white that others, and it therefore followed that some towns might be entirely white. But this seeminly rational thought gets blown apart when the author shows data from 39 states showing how blacks routinely left county after county during the 20th century. In other words, the United States was more integrated in 1900 than in 2000 - the author was not stretching the truth - its my own history that is flawed.

Why isn't this commonly known? Why has history squelched this? Why are we raised to feel comfortable about the fact that our neighborhoods and schools are almost entirely monoracial (aka segregated)? Is there some kind of white person mythology that is being passed off as truth, as history?

I am reminded of a TED talk by Nate Silver that investigates racism and voting.

It seems obvious, but people who live in racial segregation are racist. Perhaps if we want to fight racism we need to take conscious steps to live in more diverse neighborhoods.

More information about Sundown towns can be found on the wikipedia page about Sundown Towns. Also don't miss this trailer for a video about ethnic cleansing in the US.