An Auspicious Beginning in Cambodia

Our first year in Southeast Asia is coming to a close. It seems apropos that this final trip of the year for me coincides with the Cambodian Water Festival, Bon Om Tuk. The Water Festival, centered around 300 pairs of Bayon-inspired boats competing in front of the Royal Palace, is an homage to Angkor's ancient navy. The Water Festival also marks a profound ecological transition: the end of the rainy season during which the waters of the Tonle Sap River reverse and flow back into the Mekong. During this change, the waters become still.

(PHOTO: Team training for Water Festival.)

At InSTEDD, we have been racing to the finish line, and I am grateful for the still waters to reflect upon our first year and prepare for the years to come. It has been amazing to see an idea -- that free, open source software that helps people work better together can make a real difference to the domains of public health and humanitarian response -- come to fruition.

We started the year with a set of possibilities, and found ourselves at the end of the year with eighty Cambodians doing a pandemic flu simulation using geochat near the Cambodian-Laos border. We started the year meeting in cafes, figuring out who is who, and ended the year with an Innovation Laboratory where the software is being co-developed and spearheaded by people who live here in partnership with two local technology NGOs, Yejj and Digital Divide Data. There were many challenges we faced along the way, but it has all been worth it to see what is happening now.

Now that we have laid a foundation, we are ready, in these still waters, to dive deeply over the next year. We look forward to working with all of you to ensure that we are making a difference.

Empowerment practice explored...

Like my colleague Ed Jezierski, I want to share my concern for the people in Myanmar. I just spoke with a Burmese colleague in Bangkok who told me her family in Yangon is fortunately safe and unharmed. She described the damage in downtown Yangon as largely to trees and satellites on top of buildings. Electricity has been cut off but some people have generators.

Today I continue to explore the elements of effective community-based practice. My previous post was on the positive model Betty Makoni exemplifies for how to address serious social challenges, like domestic violence and rape. Her Girl Child Network employs true empowerment practice. This program, based on a network of girls' clubs, fosters the seeds of strength within the girls in the programs and encourages them to lead and effect change.

Empowerment practice is an overused word for those of us in the social work field. Everyone wants to engage in empowerment practice. One way to begin is to use a method described in an earlier post called asset mapping, which is also nicely described in the Social Design Notes. Another useful perspective is described as risk and protective factors.

Most of us know about risk factors - a history of breast cancer can be a risk factor for developing breast cancer. In infectious disease, poverty and malnutrition can be a particularly pernicious risk factors. According to the Global Health Council, "poverty not only characterizes the circumstances in which infectious diseases thrive, but the cycle of poverty is exacerbated by lost productivity, missed educational opportunities, and high health-care costs for the affected and their families."

Fortunately, poverty alone does not tell the whole story. Even in the midst of significant stressors, some people have positive outcomes. Protective factors - those factors that contribute to resiliency - are one place to look.

One of the early innovators of the term protective factors is developmental psychologist Emmy Werner, who did a groundbreaking longitudinal study on all of the children born in one year in Kauai, Hawaii. What was surprising about her work is that many of these children who were born into high risk households (substance abuse, etc) had successful outcomes. She found that 'protective factors' distinguished these resilient children. One of the most important protective factors was having a strong relationship with a nonparent caretaker or a community organization like the YMCA.

Social interventions (such as Big Brother/Big Sister) mimic and foster these protective factors. What intrigues me about this study is not just the resiliency research, but what they found to aid resilience -- social support and encouragement.

When we look at infectious disease in Southeast Asia for our Mekong Collaboration Program, we need to look not just at risk factors, but also at resiliency or protective factors: what are those qualities that make a community, village or family more likely to resist and respond to infectious disease outbreaks? Ultimately, the social and economic development of communities will be more important than fostering any single resiliency factors. In the meantime, stronger social networks strengthened by collaboration technology may help communities and public health officials respond more quickly and effectively.

Get inspired...

Wednesday night I saw Betty Makoni speak -- Zimbabwean activist and 2008 Recipient of the Ginetta Sagan Amnesty International Award for Women's and Children's Rights -- and I am still on a high from the event.

I have realized, after a career trying to improve the conditions in the world, it is really important at least every quarter to hear an inspirational person who reminds you why you are doing this work.

Betty Makoni is such a person. She embodies the word 'empowerment' and models how we can support communities to claim their own destinies. She has built a network of girls' clubs in Zimbabwe, now numbering over 30,000 girls, and these clubs develop strategies for their own growth and enhancement. Many of the members are victims of rape and domestic violence, much like Betty Makoni, who was raped at age 6 and who saw her mother killed in a domestic violence a few years later. But rather than give these girls a handout, Betty invites them to 'reach for the sky', heal their wounds, challenge societal norms around violence and build skills to live successful lives. She teaches girls to use the words donors use -- like 'strategic planning' -- and claim them for their own.

Her Girl Child Network reminds me of the elements of successful community programs:

• They tap into the strengths of people and challenge them to grow and succeed; many programs for sexual abuse victims are 'survivor' oriented. Betty wants her girls to thrive. Her healing camp for rape victims is called an "Empowerment Camp."
  
• They are not just a 'program' but are part of a movement to effect societal change, in this case the attitudes towards girls and women;
  
• They have their own energy - in this case the energy of the girls - to keep it going and growing. Betty does not have to set up girls' clubs, though she is usually there for their inauguration. They can be set up by girls' themselves and thus draw on the energy of large groups of people.

At the end of her talk, she implored the audience not just to send emails, but to stand in solidarity with her and her movement who are suffering under the current Zimbabwean government. The girls have the energy, but they need resources and support to rise above the challenges they face.

Enjoy your weekend and get inspired! My next installment will address another dimension of empowerment - resiliency.

Adventures in PP...

We have been in PP (Phnom Penh) for about a week now to start up our Mekong Collaboration Program. Cambodia is going to be the first site for our field tests, and we are working closely with the Ministry of Health and NGOs to identify the requirements and scope of our work. Our primary objective is to support the Cambodian Center for Disease Control in their ability to detect and respond rapidly to priority diseases (including cholera, dengue, and others). Our secondary objective is to develop a set of tools that can be sustained because there is a market for these tools within and beyond the health sector (and even in the commercial sector).

One of our top priorities on this trip has been to get a deeper understanding of the technology infrastructure and staffing. Our technology team, including Ed, our Director of Engineering, believe strongly the tools need to engage and draw on Cambodian talent to be useful and to enable a Cambodian team to provide support after we leave. We welcome ideas on how to build technology sustainably or connections in Cambodia you might recommend.

One of our favorite NGOs is the Khmer Software Initiative, whose vision is "a country where Cambodians can learn and use computers in their own language, a country that does not have to change to a new language in order to use computers!" We are also concerned with this question because many software applications here are only in English, including mobile phone text messaging. There are some Khmer cell phones, but their reach is still limited. A serious question we are exploring is: how will widespread access to Khmer text messaging be possible?

What is the number one killer worldwide...

Heart disease? Lung cancer? Traffic accidents? HIV/AIDS? This was one of 50 questions over 600 Bay Area teenagers had to answer as part of World Savvy's World Affairs Challenge .

This year’s theme, apropos to InSTEDD’s mission, was Global Health, and students prepared a 15 minute presentation, answered a 50 question world affairs quiz (which you can take below) and discussed a contemporary issue. I was one of the privileged judges.

I was completely inspired by the students' creative presentations and their ability to look at the challenges we are addressing with fresh eyes: they held mock trials against China's environmental protection agency, prepared faux news reports from Sudanese refugee camps, and simulated a convening of a World Health Organization conference.

Several teams chose to present on issues they felt were left out from the global health discussions, including the health effects of the contamination of Lake Tai in China, viewing the genocide in Darfur as a public health issue, highlighting the plight of the thousands women a year who die during childbirth and addressing the rise of obesity in Mexico.

More important than the content of their presentations, was their sincerity of purpose and enthusiasm for the subject.

From InSTEDD’s standpoint, the most interesting part of the day was what was called the Collaborative Question. This activity requires 4-6 teens to debate and agree on a proposed solution to a problem they receive at the start of this activity. This year they acted as Finance Officers for the mock Institute of Global Health in London. They had to decide how to spend 30 million dollars to address Japanese Encephalitis. They had the option to work in 3 countries (India, Vietnam or Cambodia) and use one of 5 interventions (education, vaccination research, pig extermination, pesticide spraying of mosquitos and childhood vaccination).

Of course I was most excited about the group who chose to spend their 30 million in Cambodia on a village education campaign. They chose Cambodia because they were concerned about its low life expectancy (54 years) and they felt, with 14 million people (relative to 1 B in India and 85 million in Vietnam) they had a chance of making a difference. I told the young people I would share their ideas on my next trip to Cambodia.

By the way, the Global Burden of Disease report by WHO found that heart disease is the number one killer worldwide. For those who are inspired to go through the entire quiz, World Savvy has graciously shared it with me.

Here's the whole World Savvy quiz if you want to take it (it's about 10 minutes). And, the answers, of course. Thank you Dana and Bryn at World Savvy!

Off to TED...

Yesterday our CEO, Eric Rasmussen and our CTO, Robert Kirkpatrick, headed off to the Technology, Entertainment and Design conference that promotes "ideas worth spreading" in Monterey, CA. Our team was invited to share what has come of the TED wish Larry Brilliant made two years ago that ultimately gave birth to InSTEDD. [Larry Brilliant included "TED" in our acronym as a nod to the conference.] Even though you (like me) will not be privy to this invite-only event, most of the amazing speeches will be posted online after the conference. I highly recommend listening to "Ted Talks" whenever you are in need of inspiration.

TED has brought together fields (tech, entertainment and design) with natural synergies. What are those natural synergies in the field of public health? I am not trying to make public health cool or glamorous; I am searching for those hooks of excitement and energy that bring people out of their silos and working together. What would attract people from animal, human and environmental health to work together (besides necessity)?

How can you make a difference in a country with over 600 NGOs?

That’s one of many questions we are grappling with as we travel through Cambodia from the capital Phnom Pehn to the remote Lao/Cambodia border. We are meeting with a range of organizations in our effort to understand the terrain and where we can share our expertise and experience in a useful manner.

As the community focal point for this project, I pay close attention to community-based initiatives. Working with the community is a theme common in many organizations we visited, and Cambodia has a number of village volunteers who serve multiple functions in support of government efforts. There are animal health volunteers, human health volunteers, malaria volunteers and HIV volunteers among others. It is impressive how many people give their own time to health-related issues.

Along with this fantastic cadre of village volunteers, however, come disease or sector specific infrastructure and reporting mechanisms. For those tracking outbreaks of disease, having many independent systems makes it very difficult to get a full picture and respond effectively. But this nut is tough to crack. Disease specific funding streams are partly driven by donors who want to see results in their area of concern. This silo approach is not only widespread here, but in affluent nations such as the United States. We are exploring ways technology might be able to build bridges and open communication.

Regardless of the professional challenges, Cambodia is a glorious place to be. I am writing this blog overlooking the majestic Mekong River which is so vast at times it resembles the sea. I plan to visit the Killing Fields of Choeung Ek and the Tuol Sleng Genocide Museum because the present cannot be understood without an appreciation for the horrific past they have endured. We learned that only six doctors survived the Khmer Rouge regime, and we have had the great honor to meet two of these extraordinary individuals. I hope we can give something back to this nation (and others in the region) that have suffered so greatly.

Thai Curry Without the Chili

That's what Fran Baum of the People's Health Movement called talking about primary health care without talking about the global political and economic conditions that lead to poor primary health care. It's mild and bland and not the real deal. This metaphor was one of many shared during the Prince Mahidol Awards Ceremony conference we are attending in Thailand.

Now you may wonder…what does primary health care have to do with InSTEDD? Everything, it turns out. A strong primary health care system is one of the best ways to encourage and protect public health. Robert Woollard, head of the Department of Family Practice at the University of British Colombia, advocates a new relationship between public and primary health. Primary health has focused almost exclusively on the individual, and public health solely on the entire community. Instead of one or the other, he suggests we think in terms of relationships. With whom are we connected? How can we build those connections? Technology may be ahead of the human side. There are already efforts underway technologically to link electronic health records with public health reporting. According to my colleague Taha Kass-Hout, in New York City when they get word of an outbreak, they send an alert to everyone whose electronic health record indicates those symptoms.

As a final, unrelated note, Thailand is an amazing place. It has fragrant juices, from lemongrass to fresh guava and a concoction sort of like a virgin mojito. It also has the usual suspects in terms of American fast food including Pizza Hut, McDonald’s and KFC. (An aside, what are the ethics on links? I really do not want to link you to the Pizza Hut page.) But strangely enough, they’ve been so penetrated by American fast food that they even have Auntie Anne’s Pretzels. Who knew there was a market for freshly made pretzels in Thailand?

Bye for now. We go to Chang Mai tonight for the Mekong Basin Disease Surveillance meeting, and then on to Cambodia.

On to Cambodia in Search of Assets...(Not the Kind You Imagine)

We leave Monday for Thailand and Cambodia to work on our Mekong Collaboration Program.

In preparation for this trip, I dug up a methodology that served me well in the social work field: the asset mapping approach. This model is not about tracking strategic assets. It is about communities focusing on their own strength and capacity. This approach often starts with a community developing a health scorecard of positive community activities, such as kids spending time with grandparents, that can then become a focus for community energy and activism.

This methodology works great when approaching general social issues, but how well does it work in the technology realm internationally? InSTEDD was hired to work in Southeast Asia because of our technology expertise. How can we share technology in a way that is relevant and empowering to communities? The obvious model is the transfer and train model, a model which many technology organizations currently use. An asset approach would take technology sharing much further than that. In the article Closing the Digital Divide: An Asset-Based Approach to Community Building and Community Technology , Nicol Turner at Northwestern and Randal Pinkett at MIT suggest that the technology itself and how it is shared should facilitate the strengthening of assets in a community. They wrote that "while e-mail and listservs are useful and value tools, we are advocating a new class of community technology, that is specifically designed to support asset-based community development" (p. 5). Technology is used to reinforce cultural identity, broaden community communciation and improve resource exchange.

Can we find ways to track infectious disease in ways that strengthen the community identity? It's tough, because infectious disease may not be the top priority of villagers in Laos or Cambodia, many of whom do not have access to clean water or adequate food. Can we serve the broader public health needs and serve community interests as well?

Welcome to InSTEDD's Community Perspectives

Welcome to InSTEDD. I am really glad you are here and interested in our mission to enhance global disease and disaster response with technology tools. In addition to managing some of the projects, my particular focus is to ensure that diverse and grassroots voices are an important part of our work, from informing the tools we refine to the way technology is shared. My background is in international politics and social work, so I come with a geopolitical perspective and a deep appreciation for how power dynamics, culture and class can complicate working with people internationally. I really care about making a difference and would love to hear your experiences on successes you have had.

We are going to Cambodia at the end of January to continue our assessment process for our Mekong Collaboration Program. Most of my personal contacts are in Africa, so if you know of great community groups or non-governmental organizations (NGOs) in Cambodia you would recommend, please let me know.

My own approach is greatly informed by my time working in a Rwandan refugee camp after the genocide with the unaccompanied minors program. Instead of coming in with our 'outsider' answers, we looked at what the Rwandans were already doing (taking in stranger's children) and supported that effort. On the other side of Rwanda (Zaire, now Congo), international media attention on the children inspired many groups to set up orphanages which encouraged families to drop off their own children so they could get more food. There were other differences between the two regions, but the two differing approaches had profoundly different outcomes. In our camp, we had 5,000 children in foster care and 20 in a care center, and in Zaire they had 10,000 children in orphanages/care centers. After that experience, I begin any cross-cultural work or community work by seeking to understand what people are naturally doing and supporting those efforts.

What experiences have shaped your own view of working internationally?

Bye for now. I will be writing weekly so check back or email me at marcus@instedd.org.

Sincerely, Mary Jane

Just Back from India

I just returned from India, a personal trip to attend a friend's wedding that also included many opportunities to explore how InSTEDD could serve the communities here. Disaster and public health are both top priorities here. India was in the midst of a major polio vaccination push, with banners displayed around Dehli encouraging families to get their children immunized on a mass immunization day - January 6th. In the eastern region, they are responding to the the once every 48 year bamboo bloom that brings with it thousands of rats and mass exoduses.

The most interesting discovery was during a conversation with my friend, Chhaya Kunmar, who works for an NGO in the Himalayan mountain regions south of Nepal. The founders of Himalayan Action Research Centre realized the greatest way they could empower people of the rural areas was to provide information. The center of HARC's platform is to share information and provide training to these rural villagers, and information alone, without direct financial aid, has had a tremendous effect. They showed villagers how worthwhile organizing into farmer groups could be, and they also introduced these farmers to large buyers who could give them better prices. These two efforts resulted in orange farmers earning from 1 cent a kilo to 5 cents a kilo. It turns out these rural villagers simply did not have easy access to information and resources that would help them improve their lives. But what is most significant is HARC's approach. They do not arrange the buying or tell farmers what to grow; they simply introduce them to better opportunities and allow the farmers to decide.

This model is relevant to InSTEDD's efforts to use technology to gather and share information more effectively in remote regions of the world.

Technology had penetrated these hill stations (though I would call them mountains they were so enormous) but to a lesser extent than one would think of India. In the village of Naugaun in the state of Uttranchal, some farmers have cell phones, and anyone with a job outside the subsistence sector has a cell phone. There was no internet cafe in the village, and computers were definitely limited to the NGO, and were further limited by the regular power outages in the village.