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The Complexity Matters blog features the Thursday Complexity Post as well as other complexity inspired news items.


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Tragedy Inspires Choices for Change

Posted By Prucia Buscell, Thursday, October 2, 2014

During his service in the U.S. Marines, Jake Harriman saw war and conflict in Southeast Asia, Africa and the Middle East. A horrifying experience in Iraq changed his view of the world and the course of his own life.

He was a Special Operations platoon commander waiting for supplies on a highway to Baghdad in 2003 when Americans fired warning shots at an approaching car they feared might be full of explosives with a driver on a suicide mission. An Iraqi man leapt from the car and ran toward the Americans, waving his arms frantically. An Iraqi military vehicle suddenly roared to the scene, sprayed his vehicle with bullets, and sped away. The man, accompanied by Harriman, ran back to the car to find his wife and two children fatally shot. The Americans didn't know it at the time, but the Iraqi was trying to escape the effort of Saddam Hussein, then still in power, to coerce poor farmers to sabotage coalition forces in exchange for food.

Describing those events to The Christian Science Monitor, Harriman said,

"Something awoke inside of me-an anger that burned and grew. That day I vowed to devote my life to giving people choices and hope where none previously existed."

Five years later he founded Nuru International, an organization dedicated to ending extreme poverty. To prepare for this task, Harriman applied and got into Stanford University's graduate school of business, where he studied economics, computer modeling, and how to "design for extreme affordability" to get goods and services to the poorest of the poor. The World Bank defines poverty as living on $1.25 a day. Harriman looked deeper. Incorporating ideas of economists Mahbub ul Haq and Amartya Sen, Nuru views extreme poverty as lacking choices necessary to attain basic human rights. That's more than avoiding starvation. That means addressing health, education and seeking conditions that foster resilience in the face of catastrophe.

Stanford Professor James Patell, who taught Harriman, told The Monitor Nuru differs from many anti-poverty efforts in the developing world in that its goal is sustainable projects that will be operated by local communities, and in its commitment to bringing its model into war-torn areas. Harriman explains in his blog that the work began in Kenya because he and colleagues wanted to build and test their prototype in a relatively stable country before trying to introduce it into a chaotic failed state or conflict zone. "We are attempting to build a high impact integrated development model that is completely self-contained-that is it can scale on its own-funded by capital produced in-country and led by nationals equipped to innovate and effectively manage large scale projects."

Harriman said that Nuru seeks local community participants who are true "servant leaders" who work to distribute power rather than consolidate it. Nuru is a Kiswahili word that means light. Harriman was recently honored as a veteran entrepreneur in the White House Champions for Change program.

Tags:  buscell  complexity matters  leadership 

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Army Women Create Mentoring Network

Posted By Prucia Buscell, Thursday, March 20, 2014

The Army is making more of its positions gender neutral but women are still a minority in the rank and file and an even smaller minority in leadership. The new Women's Mentorship Network at Fort Hood, Texas, is designed to move the numbers by cultivating capable, resilient female leadership.

Major Heather Gunther, communications officer for the 3d Brigade Combat Team, First Cavalry Division, sees mentorship as a professional responsibility. She recognizes the math problem: women make up only 17 percent of all active duty forces, and women are underrepresented in the brigade combat team of more than 4,500 soldiers. Those numbers will grow as the Army opens more previously closed positions to women-there could be more than 10,000 positions newly available to women by early next year, and as many as 90,000 in five years. Just a year ago, Major Gunther, a signal officer, could not have served at the Battalion level. Only a man could be the signal officer in a combat arms unit. The Fort Hood cavalry division was one of the pilot units for the Women in the Army research and is now leading the way in gender integration.

"When you look at that many soldiers, and recognize the relatively few women, you feel a real professional responsibility," Gunther said. "There are professional development groups for officers and Fortune 500 companies have employee engagement groups and networks. We wanted something powerful for women in the military."

Gunther and colleagues started by holding brown bag lunches where people could come voluntarily, on their own time, to examine issues women face aspiring to professional growth and leadership. "We had battle buddies up and down and across the installation asking 'can we come,' and before we knew it, there were circles of women meeting everywhere, wanting to expand the conversation to non commissioned officers and junior enlistees. We talked about mentorship, role models, challenges, opportunities, and psycho-social supports."

The Army has a long tradition of male mentoring, and many famed leaders were beneficiaries. Just to name a few, Major General Fox Connor, operations officer for the American Expeditionary Force during World War I, mentored Dwight Eisenhower. While Eisenhower was on his staff, Connor designed a course of study in which Eisenhower did extensive reading in military history and had daily practice writing field orders for every aspect of command. General George Marshall, the Army chief of staff when the U.S. entered World War II, mentored Omar Bradley, who eventually presided over the American D-Day landing on the beaches of Normandy.

Gunther notes that the Army's senior leadership has cited the need to create conditions and support that will help develop women leaders. She adds that some of her own best mentors have been men, and she wants the new group to empower men to join women in positive, informed discussions. To be inclusive and transparent, the Womens' Mentoring Network (WMN) is open to men and civilians as well as Army women. And as Gunther puts it, the organization has to be "scalable and starfishy." Before coming to Fort Hood, Gunther had been at the Army's general staff college at Fort Leavenworth. While there, she participated in a 2011 leadership development program with Ori Brafman, the author of The Starfish and the Spider, a book about successful organizations that are decentralized and adaptive. She also met Lisa Kimball, a former Plexus Institute president, organizational development leader and skilled facilitator, who has worked with the Army on leadership development. She conferred with both about the WMN and she and colleagues decided to infuse the new venture with some of the processes and practices that had inspired participants in the groups at Fort Leavenworth.

When WMN was launched in January, 60 women attended a clinic directed by Brafman, and since then 19 women have been trained as facilitators who know how to guide discussions and use such techniques as improv, and several Liberating Structures that can quickly identify crucial questions and issues even in a large group. Each facilitator hosts a one hour session according to her schedule, so participants can select the session best suited to their schedules and needs. Facilitators introduce the interactive exercises in ways designed to engage attendees as both mentors and mentees, depending on the situation. In that way, participants can develop relationships, form networks and share resources even when they are deployed.

While WMN members can bring up a range of issues, Gunther says, including controversial ones if they wish, facilitators help keep the discussions focused on professional development and leadership and at the same time maintain military values of respect, service and trust. While women's mentorship initiatives have formed at half a dozen Army bases, not all have generated wide support. One in Georgia that featured the slogan "divas in boots" and offered advice on household tips and couponing aroused the ire of military women who complained it was "too much June Cleaver and too little GI Jane." Gunther doesn't dismiss domestic concerns. She just wants the women in WMN to maintain the vision of career development and a support system that will eventually enrich the Armed Forces with experienced, confident women who are ready to lead when the opportunity arises.

Tags:  buscell  complexity matters  leadership  scaling 

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Leaders Face New Challenges in a Networked World

Posted By Prucia Buscell, Thursday, February 13, 2014

The language of leadership often reflects hierarchy and elaborates distinctions between leaders and followers. The "great man" theory of history proposed by nineteenth century philosopher Thomas Carlisle still offers an appealing view of extraordinary men and women shaping and moving events through their own personal strength and charisma. Scholar and author Mila Baker, PhD, argues one of the most profound social shifts in recent years has been erosion of individual power and the rise of collective power enabled by technology and social media.

"We need a mindset and language of leadership that maintains equilibrium between leading and following-a conception of leadership that is agile and stateless in its composition," she writes in her new book Peer to Peer Leadership: Why the Network is the Leader. "Like the U.S. Constitution guides and influences the nation's trajectory without stifling the rights and freedoms of its populace, organizations' design needs to facilitate leading and following on an equal platform."

Dr. Baker isn't saying CEOs have no role. She is saying today's changing business world requires them to adopt new thinking and behavior. In the architecture of a peer to peer network community, every computer-or electronic device-represents a node. The network connects people and provides instant flow of information. All nodes within the network are equal participants in a larger whole, a concept Dr. Baker calls equipotency. Electronic technology is no longer just a tool in organizations. It changes the way we relate to one another. It enables information to be sent and received among peers working toward a common goal. Everyone leads and everyone follows. Dr. Baker tells of her own experience working in a psychiatric emergency room. Each individual had an equal opportunity to contribute, which was not defined by an individuals' role or position, but the need of the moment. "We shared power and authority-we followed and gave orders as necessary," she writes, all respecting each other's commitment to the wellbeing of patients. "In general, she says, "equipotency blurs the line between leader and follower, and at the same time clarifies the overall purpose within groups and organizations."

The dynamic action needed to respond to a situation, she says, "occurs at the intersection of art and science." That's the relational dynamic that develops within a network when all perspectives are heard, integrated and accounted for. The network becomes the leader, Dr. Baker writes, because actions are based on a consensus of needs.

So what is the paradigm for new leadership? Dr. Baker says leadership can only be demonstrated in the context of a relational dynamic. She describes leadership as a "dyad exchange structure." She says this kind of leadership is shown by "the catalytic action that occurs in the relational dynamic between two individuals working together toward a common goal." In organizations that have successfully evolved away from the Industrial Age individual-centered command and control model, dyad exchange structures will connect nodes-people-for the purpose of resolving polarities and innovating. Dr. Baker says these structures will strengthen the bonds among people, enable the network to do its work, and allow us to embrace technology "as an extension of our capacity to evolve as humans in a connected world." The connected world means we need to move beyond the idea that leadership is limited to individuals, and that information should flow mainly from boss to subordinate. Networked information in organizations means more openness and more agility. Hazards associated with increased openness can be mitigated by technology that quickly uncovers patterns and identifies risks.

Tags:  buscell  complexity matters  leaders  leadership  networks 

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Soft Traits that Drive Corporate Culture

Posted By Prucia Buscell, Thursday, January 16, 2014

How can business ventures grow and retain the commitment, passion and agility they had when they started? Distilling patterns from interviews with more than 200 CEOs, business writer Adam Bryant identifies six elements he believes every organization needs to foster a culture that encourages innovation and drives results.

In his New York Times article "Management be Nimble" he describes what he calls the main drivers of corporate culture-the things that will have outsize positive or negative impact, depending on whether they are done well or badly. Many business scholars and theoreticians support his views.

To start, leaders need to boil down an organization's priorities into a simple plan that also identifies clear goals and metrics. At the insurance company FM Global, he writes by way of example, the operating framework is profitability, retaining existing clients, and attracting new ones. Of course, not all simplification is that easy. The University of Oregon Holden Leadership Center website offers some goal definition steps that can help aid direction and avoid chaos.

Rules of the road, Bryant writes, involve behavioral guidelines, development of accepted values and a commitment to live by them. When people see a disconnect between stated values and real action, Bryant suggests, the cancer of cynicism can metastasize.

Writers from Goethe to Emerson to Tupac Shakur have weighed on in the concept of respect, and much has been written about office bullying and other unproductive work behavior. Bryant quotes Robin Domeniconi, chief marketing officer at Rue La La, a flash sale site, who uses the expression "M.R.I" to describe her firm's cultural guide. That means "most respectful interpretation" of what a person is saying. David K. Williams, author of The 7 Non-Negotiables of Winning: Tying Soft Traits to Hard Results, writes in Forbes about respect as one of his non-negotiables.

Bryant also writes about the importance of teams, the ability to have difficult conversations and the hazards of email. Despite speed and convenience, email can be a dangerous trap. In "How to Avoid Virtual Miscommunication" a post on his Harvard Business Review blog, Keith Ferrazzi writes that we often convey less information than we think, less clearly than we think, and we make more assumptions than we realize about the recipients of our messages. Ferrazzi inveighs against sloppy presentation and cryptic meaning, and urges we remember that the medium is the message: that we think about whether a text, IM, video, or email is suitable for the content we are sending.

Bryant is the author of Quick and Nimble: Lessons from Leading CEOs on How to Create a Culture of Innovation. He also writes The Corner Office, a regular New York Times business feature. Read his New York Times essay here.

Tags:  buscell  complexity matters  culture  leadership  organizations 

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Tragedy, Myth and Leadership

Posted By Prucia Buscell, Thursday, December 12, 2013

We're hard wired for stories, and classical scholar Daniel Mendelsohn says the myths and dramas of ancient Greece are so embedded in our consciousness that we can't help but revisit them as we interpret contemporary culture. One example, he says, is our obsessive need for anniversary replays of film footage and commentary on President Kennedy's death and the days of shock and mourning that followed. Our conflicted desire to marvel at charismatic leaders and to witness their fall, he says, is rooted in Greek tragedy.

In a New Yorker essay J.F.K, Tragedy, Myth, Mendelsohn, a professor at Bard College, says Kennedy's assassination on November 22, 1963, and the many other traumatic events and deaths in generations of the Kennedy family, reflect elements in Greek tragedy. In many tragedies, including the plays of Aeschylus and Sophocles, he writes, the all-knowing gods are "pulling the strings unbeknownst to the mortals whose lives they control; works like Oresteia and Oedipus, (whose hero learns to his horror that he cannot escape the plot the gods have written for him), seem to confirm an invisible but palpable order of things."

These ancient stories distill certain vibrant narratives in an elemental way that animates all cultures, Mendelsohn says. In fact, he writes, we have a desire to find a plot "in the hodgepodge of events we call history." And he says our impulse to make sense of events, to expose past secrets, and to present evidence of past deeds to present-day audiences, helps fuel elaborate conspiracy theories about the assassination. Tragic thinking, the way Aeschylus thought, he writes, encourages us to seek dark patterns behind events, and suspect all happenings are connected to the past, and that the sins of the fathers are connected to the suffering of their children and their children's children.

We're a visual society, he continues, and the horror and shock of Kennedy's death was intensified because it happened before people's eyes and was captured on film. Spectacle is at the root of drama, he notes, and the need to keep watching replays is part of the Kennedy trauma. And he adds that we watch the whole spectacle-the horror, the mourning, and the ceremonial conclusions-also important in Greek tragedies-that reassure us order can be restored. He speculates the equally traumatic assassination of Abraham Lincoln may have been less obsessively replayed because it wasn't visual in the same way.

In a New Yorker podcast, Mendelsohn says it's no accident that democracy and tragedy flourished in partnership in 6th century Athens. We want great leaders, but our democratic anxieties make us distrustful of them, Mendelsohn observes, so the mythical and tragic stories of leaders brought down help us work our way through our competing attractions and suspicions. One recurring theme in Greek mythology is that the most beautiful, brilliant, remarkable humans do things that invoke the envy or wrath of the gods, who cut them down. It's a theme that has to do with a boundary that needs to be maintained between human excellence and the divine, Mendelsohn says, and one that people grapple with as they contemplate greatness and ordinary lives.

In the podcast, Mendelsohn speaks of other news events that evoke myth. The sinking of the Titanic, a ship that was too grand, too beautiful, too glamorous, and lost in man's struggle against nature, is one example. The difficulty of finding a burial place for Tamerlan Tsarnaev, the accused Boston marathon bomber who was shot by police and run over by his brother, replays the ancient and culturally fraught issue of what to do with the body of an enemy, and the definition of what an enemy is. Refused burial in Massachusetts, Tsarnaev was eventually buried quietly in Virginia. Read Mendelsohn's enlightening and provocative New Yorker piece here and listen to his podcast here.

Tags:  buscell  complexity matters  culture  leadership 

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Leading, Learning and Transformational Change

Posted By Prucia Buscell, Thursday, September 19, 2013

Eight years after Novant Health formed through the merger of two large regional hospitals in North Carolina, some executives realized, the organization still had multiple cultures, a wide variety of policies, strategic plans and information systems, and leadership development suffered as a result.

Presbyterian Healthcare in Charlotte and Carolina Medicorp in Winston-Salem merged in 1997, creating a system that now has 14 medical centers, 360 physician clinics, 158 outpatient clinics and 25,000 employees. In 2005, two of Novant's key leaders decided to begin a leadership program that would develop a pool of internal talent to fill the many new leadership roles they knew would be needed as the organization grew, and address cultural issues that could potentially undermine that anticipated growth.

Vic Cocowitch, a leadership and organizational consultant in healthcare, Stephen Orton PhD, who works for the North Carolina Institute for Public Health at the University of North Carolina, and the two Novant executives, Jacque Daniels, Chief Administrative Officer and Debbie Kiser, Vice President of Leaning and Development, describe their seven year program in a story in the OD Practitioner, the journal of the Organizational Development Network. Their article, "Reframing Leadership Development in Healthcare," explains that Leadership Novant was based on the beliefs that leadership is continuous learning, that the work environment in a healthcare system can be used as a great learning laboratory, and that managers and leaders need to learn through their own experiences.

Novant relies on interdisciplinary teams collaborating to improve patient safety, quality of care, and solve problems, the authors write, so Leadership Novant stressed teamwork throughout its curriculum in readings, assessments, simulations and social activities. A cohort program, of five three day sessions held at an off-site facility, included activities that helped participants deepen personal relationships and networks and think and act outside of their usual comfort zone. It emphasized three themes, which the article describes as follows:

The Use of Self is based on the idea that effective leadership depends on deep self-awareness and "an ability to intentionally manage and deploy self for desired organizational impact."

Team Leadership, which requires interdisciplinary collaboration, included such action learning projects as development of a health literacy program, analyzing post-acute care facilities and strategies, and developing a "cultural due diligence process" for potential mergers and acquisitions.

Systems Thinking and Change Leadership, which were reinforced throughout the program, were emphasized through learning content aligned with organizational needs. Case studies showed system wide change as it took place. As one example, leaders presented early plans for the inception of new health information technology in inpatient facilities and physician practices.

The authors write that a successful leadership program needs to be fully supported by the organization's CEO and entire executive team, and it needs to evolve continually so that critical and unexpected events are used as learning opportunities. An earlier article by Cocowitch and Orton about an organizational development approach to healthcare leadership and the program at Novant is available here.

Tags:  buscell  complexity matters  healthcare  leaders  leadership 

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Making “Best” Even Better

Posted By Jeff Cohn, Thursday, June 13, 2013
Updated: Friday, September 19, 2014

The dictionary defines bestas "of the highest quality, excellence, or standing.” From this comes best practices, which Wikipedia defines as "a method or technique that has consistently shown results superior to those achieved with other means.” The definition continues, "a ‘best’ practice can evolve to become better as improvements are discovered.” What happens to our drive for improvement when we hear a practice being referred to as best? I think there is a natural tendency to think only about the first part of the definition and assume that our work is done. Couple that withthe fact that many things referred to as best practices are developed elsewhere and "shared” with us for us to "adopt.” Often these decisions are made near or at the top of our organizational hierarchies, and the challenge becomes one of implementation: "do what worked for them and it should solve our problems too.”

I met a colleague this week that arrived at her current healthcare role via a pathway that brought her to Silicon Valley. She has been struck by the tendency for healthcare workers to look to their "superiors” for permission prior to trying something new. She stated that things were quite different in the IT world. People, recognizing situations in which improvements were needed, took the initiative to try to make changes and then inform their bosses about the results of those experiments. There was a culture of ongoing improvement that included and, in fact, relied on the idea that for many of our problems, we’re going to have to discover solutions that work for us.

I believe that our organizations and communities need a learning approach to improvement. We may learn that someone else’s best practice is exactly what we need, and then enthusiastically go about implementing it. We may find that we can improve that practice as "improvements are discovered” that the originators hadn’t found. Maybe those improvements are intimately intertwined in the relationships, processes, and culture of our particular organization/community. In that case the improvement works for us and won’t work for others. For this reason we may learn that what was a best practice for someone else actually isn’t useful for us, because the "superior results” were intimately intertwined with someone else’s relationships/processes/culture and are not transferable to ours. We may actually discover that there already exist superior results that work for us- our internal best practices, our positive deviants, whose practices our organization/community will embrace once they are able to discover them from their peers. And, finally, we may find that we have to create our own solutions through an iterative process of innovation, experimentation, and continuous learning.

There is a clear link with all of this and how leadership occurs. A focus on imported best practices is consistent with a traditional hierarchical leadership model, as "solutions” flow down into the organization from above, leaders providing both the vision of what needs to happen and how to do it. The learning approach requires what Plexus Institute Board member Mary Uhl-Bien, PhD calls complexity leadership. Formal leaders create the conditions for the emergent learning necessary so that those who own the work can make decisions most useful for them. They provide a general vision and acknowledge there is no clear path for getting there, enabling and supporting the multiple possible "hows” that may work in local contexts. For me, organizations embracing this approach to improvement have the potential to go beyond best practices and become truly best.

Tags:  catching butterflies  cohn  community  leadership  organizations  technology 

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Disruption Inevitable But Not Always Disastrous

Posted By Prucia Buscell, Thursday, June 6, 2013

Globalization, technological change, huge financial crises, political turbulence and natural disasters in the last two decades have made disruptive events virtually inevitable in business and industry. Yet some companies manage better than others and some even come out ahead.

"Captains in Disruption," a Strategy + Business article by Ken Favaro, Per-Ola Karisson, and Gary L. Neilson, reports on the experiences and actions of CEOs who not only guided their organizations to survival but were able to shift trouble and turbulence to organizational advantage. To lead effectively in such times, these authors say, CEOs have to anticipate the kinds of disruptions their companies may face, including natural disasters in remote locations that could disrupt their supply chains. Then they have to prepare an adequate response, and find a way to implement it effectively. And of course, none of that is easy.

They quote Clayton M. Christensen, professor and management professor who first examined the dynamics of disruption in his book The Innovator's Dilemma: When New Technologies Cause Great Firms to Fail. "How can you make sense of the future, Christensen asks, "when you only have data about the past? That’s the role of theory, to look into the future.” That means being able to analyze data to spot changes and figure out what they mean, which is especially hard when analysis depends on the strength of the limited data and risk models. Further, Christensen says, leaders often lack candid insights from people at all levels of the organization, which they need plan effectively.

Responses to disruption may need organizational redesign and culture change, the authors write, and if top executives have become isolated, they need to begin interacting informally with people throughout the organization who understand first hand what works and what doesn’t. Cross-organizational interaction, the authors write, is by far the biggest accelerator of change.

Antony Jenkins is an executive who took on a tough job during a time of disruption. In mid-2012, Jenkins was head of the retail and business banking division of Barclays, then the U.K.’s second largest bank. Then the LIBOR rate rigging scandal broke, exposing a series of fraudulent actions connected to the London Interbank Offered Rate (LIBOR), a primary benchmark for short term interest rates around the world. The bank’s chairman and CEO resigned, and Jenkins took over as CEO. The article explains Jenkins immediately informed the bank’s 140,000 employees that the focus on short term goals and immediate profits were out and a new long term strategy for transformation was in. Jenkins says the "cataclysmic experience” made people ready to listen. Jenkins emphasized involving all stakeholders in asking the right questions to move forward. In addition to bank employees, he met with politicians, media, consumer groups and regulators and listened to their criticisms.

The organizational change needed to respond to this cataclysm, Jenkins told S+B, "is about being continually dissatisfied with that you are doing...It’s about constantly challenging and creating an organization that is never satisfied.” What makes that kind of thinking hard, Christensen told the authors, is the human tendency to be complacent and forget to ask good questions. As an antidote, Christensen points to the famous phrase of former Intel CEO Andy Grove: (and the title of his book) "Only the Paranoid Survive." Read the S+B story here.

Tags:  buscell  complexity matters  leadership  organizations  resilience 

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Sixth Annual Unite For Sight Conference: Insights and Innovations in Public Health

Posted By Prucia Buscell, Friday, May 15, 2009
Updated: Tuesday, February 15, 2011
Goals for a dignified and decent life on our planet have been enunciated three times in the last 60 years, and timetables and accountability are the only hope of achieving them, in the view of Jeffrey Sachs, an economist, professor and director of the Earth Institute at Columbia University.

In 1948, the Universal Declaration of Human Rights had profound significance around the world as people tried to recover from the ravages of World War II, Sachs said. In 1978, the Declaration of Alma-Ata proclaimed health as a fundamental human right. In 2000 the UN Millennium Development Goals constituted an international agreement to reduce extreme poverty, disease and hunger by the year 2015.

The goals have not been met, Sachs said, but the wisdom of the documents is still alive, and like all great documents they need to be renewed and refreshed by each new generation.

"The goals declared at the start of the new millennium were full of hope and renewal,” Sachs said, asserting that security, safety, health, and educational opportunity, as well as freedom from conflict and preventable disease, are basic human rights. Rather than defining poverty in terms of dollars, he added, the document recognizes that extreme deprivation is multi-dimensional and needs to be addressed in a multi-dimensional way.

It is inexcusable that nine million children die before their fifth birthdays, when nearly all of those deaths are caused by extreme poverty, Sachs declared, adding it is a disgrace that children die of malaria for lack of a $5 bed net, that women and infants die because of unsafe childbirth, and that pandemic, parasitic, infectious and controllable diseases cause suffering, blindness and death.

"We need to keep these goals alive, and hold leaders accountable. That is our most important tool,” Sachs said. "We need international leadership. The new world is multi-national, and any solution needs to be cooperative….We are networked. The joy of our time is that we can cooperate in ways we couldn’t even think about in the last century.”

Corporations, businesses, nongovernmental organization, universities, scientists, civil society and individuals can collaborate and create partnerships to find solutions, he said, adding that he sees himself "as a plumber, making connections across these areas, finding ways to make the pipes fit.”

Sachs was a keynote speaker at the Unite For Sight sixth annual Global Health Conference at Yale University April 18-19, 2009. Unite For Sight is a nonprofit organization founded to empower communities worldwide to improve eye health and eliminate preventable blindness. The conference drew more than 2,200 participants from 50 states and 55 countries and a multitude of disciplines, to exchange ideas in all areas of public health and international development. Presenters included physicians, nurses, professors, organizational development practitioners and workers and specialists from dozens of public health-related fields. The following summaries represent just a few of the presentations and discussions at this extraordinary event.

Idealism is Not Enough

Nicholas Kristof tells a cautionary tale about cassava farming in Nigeria.

He recalls that he and his wife worked on a farm where women were raising cassava they ate and sold. Their cassava bed had a low yield, so they welcomed the opportunity for a new variety of the plant that yielded five times more crop. But they didn’t have the time or equipment to harvest it all. Further, the cassava plants absorb mercury and arsenic in areas where it remains in the ground from earlier gold mining operations, and the plant itself has naturally occurring chemicals that trigger production of cyanide. So the increased processing was polluting the ground water. The crop, however, was making money, and men decided they should be in charge of a cash crop. So they took over the operation, and the women were left with nothing.

"Idealism is not enough,” Kristof said. "You need grass roots understanding. There is a danger of making things sound too easy. Ideas are easy. Acting on them is a difficult. And you need to learn form your mistakes.”

Kristof, the Pulitzer Prize winning New York Times columnist who has written stories about human suffering and courage in remote trouble spots all over the world, urges would-be activists, "When you think you know what’s happening, back off. Travel in grass roots areas, find a cause larger than yourself, and get out of your comfort zone. You have to be bewildered.”

Kristof addressed the Unite For Sight conference last month at Yale. People are sometimes dubious about whether aid interventions work, he said, but they are necessary and they can help. See his May 13 column "What A Little Vitamin A Can Do” to combat unnecessary blindness among people in Africa.

Grass roots efforts tend to work best, he said. Great effort has been expended since 1970 to reduce female genital cutting in Afghanistan, he said, but conferences and new laws have had little impact. What helped a great deal was getting girls to school. Politics also may not be helpful. In combating AIDS, he noted, conservatives want abstinence and liberals want condoms, but the most effective approach may be something else. Girls in school who have learned the AIDS rate among middle-aged men are less likely to become involved with "sugar daddies,” despite the economic pressures to find financial help from older men. Kristof was one of several presenters who observed that when girls are educated and women have more social influence, poverty declines. More money is spent on children and small businesses and less on alcohol, prostitution and other vices.

Years ago, Kristof said, a New Yorker donated $100 to educate bright girls in a Chinese village he had written about. The bank erred, and gave the village $10,000. On a return visit 15 years later, Kristof found girls’ education and scholarships continuing, and many more educated young women holding good jobs, starting businesses, and educating their siblings.

Infectious and Chronic Diseases: Today’s Health Threats

Susan Blumenthal, MD, a former US Assistant Surgeon General who is a professor at Georgetown and Tufts University Schools of Medicine, spoke of trends and changes, not all reflecting progress. In 1969, she said, the US Surgeon General declared the battle against infectious disease had been won. Today, she said, the greatest health threats world wide are infectious disease and chronic disease.

Since 1972, she said, more than 32 new infectious diseases have emerged, and 1,500 people die every hour world wide from infectious disease. When people and animals live in close contact, pathogens flourish, and modernization and international travel facilitates dissemination. Climate change and extreme temperatures also foster emergence of new diseases that are water borne, air borne, and carried by rodents and insects. She added massive forest cutting promotes lymes disease in humans.

"We need public health policy that focuses on chronic disease,” she said. "We need to combat childhood obesity: 24 percent of our kids are over weight, and diabetes is becoming epidemic.” Inactivity, which contributes to obesity, impacts every organ system in the body. She added that one fifth of American children are shorter than children of a decade earlier. Published reports have documented that Americans are no longer the tallest people the world.

Disease and "Socioemergence”

A collection of interacting economic, political and environmental processes over several decades may have facilitated the movement of the viruses, Simian Immunodeficiency Virus SIV and Human Immunodeficiency Virus HIV, from nonhumans to humans. Rebecca Hardin, PhD, an assistant professor at University of Michigan’s School of Natural Resources and Environment has studied "socioemergence,” the political and cultural dimensions of emergent viral diseases in Africa’s equatorial rain forest. From 1890 to 1930, she said, the area was under brutal colonial control, with forced labor drawn from small villages for logging and road building. Because the environment does not lend itself to raising cattle, workers were fed wild game. In later decades increased hunting and a growing trade in wild game meat was a threat to African wildlife in the Congo Basin, where the populations of chimpanzees and other primates plunged. Continued road construction from remote areas and human migration increased environmental pressures. Researchers found high HIV prevalence among women in commercial logging areas, and theorized that their vulnerability was related to the social and economic networks created by the industry. The Bushmeat Crisis Task Force website says wild game commercialization is a human as well as natural tragedy: loss of animals means endangered livelihoods and food insecurity for indigenous and rural populations most dependent on wildlife in their diet, and bushmeat consumption is increasingly linked to deadly diseases like HIV/AIDS, Ebola, and Foot and Mouth disease.

Mosquitoes and Malaria

Malaria is a preventable and curable disease that kills a million people a year, most of them children in Africa. Marcelo Jacobs-Lorena, PhD, a malaria researcher and professor in the department of Molecular Microbiology and Immunology at the Johns Hopkins School of Public Health, is seeking ways to increase the arsenal of weapons against mosquitoes. Mosquitoes bite an infected person, then pass the malaria germ to the next person they bite. Bed nets offer some protection for people sleeping. Insecticides bring resistance, Dr. Jacobs-Lorena said, and as soon as all the mosquitoes in an environmental niche are killed, more will come to fill the niche. A malaria vaccine does not yet exist. "We will never conquer malaria with a single approach,” he said. "We will have to do multiple things.”

Dr. Jacobs-Lorena’s research involves genetically modifying mosquitoes so that they will be resistant to the pathogen and unable to transmit it. That has been achieved, he said, and the next step, still being researched, is to spread the resistant gene to the rest of the mosquito population.

"Let the people Lead"

Pamela Lynam, MD, is country director for JHPIEGO in Kenya. (That’s pronounced Ja-pie-go-, and its one word, not an acronym.) In her Unite For Sight presentation she stressed letting people lead the way toward health in urban slums. By 2030, she said, three of every five people on earth will be living in cities, and 95 percent of urban growth is in the developing world. One third of all urbanites world wide live in slums, and 72 percent of African urbanites are slum dwellers.

The characteristics of slums, she said, include poor quality health care, lack of access to a hospital, lack of access to public services, good drinking water, and sanitation. "You’ve heard of the flying toilets of Nairobi? People use plastic bags and then throw them,” she said. "Sixty percent of the people live on five percent of the land. And officially, they are not there, so they have no rights where they live. No one has to supply them with water, electricity, or anything else.” Such conditions promote distrust between communities and health services that do exist, she said, with real issues of insecurity and neglect. Breakdown of traditional social structures in urban slums mean large numbers of HIV deaths, children given to neighbors, violence, and very sick patients.

The traditional approach to aid, she said, has been to have experts tell people what they need. The better approach, used by JHPIEGO and many others, is to let people define their needs, and have aid directed towards fulfilling the needs. For example, she said, in one large slum near Nairobi, an aid organization offered to bring people clean water, and was surprised to find what they really wanted. "People said that’s fine, we do want clean water,” Dr. Lynam said, "but first we’d like covered bus stops, because we get soaked waiting for buses to go to work.”

The community-owned JHPIEGO intervention included anti-rape training, peer education, a village health committee, and a community theater. A community garden is generating small income and better nutrition. A self-defense group made a map of their own community showing places where people can get medical help and counseling, and its members have helped victims of rape and other crimes file police reports so that suspects are charged. They have also traveled to other communities to help others address their local needs.

"Great things happen when people start to respect and appreciate each other,” Dr. Lynam said. "The key is having people come up with their own solutions, and building trust, which takes time and patience, as well as enthusiasm and energy. You have to have a local staff. Consumers do know their own health challenges, and the results are sustainable because they come from all stakeholders.”

Dr. Lynam added that monitoring and evaluating aid programs is a very big challenge that carries with it the need for flexibility from policy makers and donors.

Women as Change Agents

Educated, empowered women are society’s change agents and the key to community health, said Jill Lester, president and CEO of The Hunger Project, a non profit that fights poverty not by direct aid, but by mobilizing women and forming partnerships with government. The organization operates in eight countries, using an "epicenter strategy”, in which clusters of villages that have up to 20,000 people work together to improve health, education, sanitation, or start small businesses. "If a woman can earn enough income so that her family goes from one to two meals a day, it changes her relationship with her husband,” Ms. Lester says. "The whole family changes if the mother has enough money for her family to eat.” She described a group of women in Senegal used a small loan to begin manufacturing a vitamin supplement for children using millet and nuts. In the process they learned skills in nutrition, hygiene, marketing and finance. A women who was illiterate a year ago now takes pride in being able to read her Bible, have soap and water in her house, and handle money without being cheated.

Destruction and Building Back Better

The Chinese got it right, Neil Boothby says: Crisis does represent both danger and opportunity. The aftermath of the devastating Indian Ocean tsunami that struck just before Christmas 2004, killing more than a quarter of a million people, also brought some beneficial legal and social changes.

Boothby is a professor and director of the Program on Forced Migration and Health at Columbia’s Mailman School of Public Health, addressed a session entitled The Epidemiology of Human Rights. He has studied efforts to protect children and families in war and disaster, and described several positive changes that developed from viewing emergency responses through a human rights-based lens. For one thing, he said, the tsunami was a tipping point for cessation at the time of civil war in Sri Lanka and Indonesia In Aceh, an emergency response framework resulted in establishment of family tracing and legal changes to protect children. New laws banned children from leaving the country alone so that child kidnapping and trafficking was greatly reduced. Police patrolled bus stations and created special desks in police stations for women and children. Before the new laws, only eight percent of children accused of crimes had lawyers, so a child who stole a piece of fruit would receive the same treatment as one who committed a felony. After the change, 71 percent of accused youngsters were represented, and the rudiments of a juvenile justice system was begun. In addition, 82 percent of children who were separated from their families in the disaster were placed with families or reconnected with relatives as a result of a family search program. Under the old system, orphanages would recruit and pay families for bright children with good academic records. A large Muslim nonprofit organization that formerly supported orphanages is reexamining its policies.

In Sri Lanka, a proliferation of orphanages came to be viewed as a secondary cause of family separation. Government and non-government agencies have started finding ways to reduce institutionalization of children, and to create safe recreational space where large numbers of children can be reached with basic social supports. Social spending has been increased in Sri Lanka and Indonesia since the tsunami.

Violence Against Women

Marie Skinnider, MD, Health Advisor to Medecins Sans Frontieres/ Doctors Without Borders, Canada, described the "consequences of gender-based violence in Papua New Guinea,” which has one of the world’s highest rates of domestic and sexual violence. One of her patients, in the first trimester of pregnancy, was gang raped while walking across a field in mid-afternoon. She had returned to her parents’ home because of domestic violence, and it appeared her husband had arranged the attack as revenge for her leaving him. Dr. Skinnider cited national survey data showing 67 percent of wives say they have been beaten by their husbands, and 60 percent of men say they have participated in gang rape at least once. The violence, she said, is generated and reinforced by the low standing of women in society: women are regarded as property of their husbands, and there are traditions of bride price and polygamy as well as a history of compensation and retribution attained at the expense of women. These social forces contribute to men being pressured by their peers to control women in their homes. Many women do not feel empowered to seek medical help, Dr. Skinnider said, and lack of transportation also prevents many women from going to health clinics.

Liberation Medicine in Education and Action Toward Health For All

Lanny Smith, MD is Professor of Medicine in the residency program of primary care and social medicine at Montefiore Medical Center, Albert Einstein College of Medicine in The Bronx, New York. He sees patients from the Highbridge and Morrisania sections in the Bronx, communities that are predominantly Hispanic and African American and that have extremely high poverty rates. He is also assistant director of the Human Rights Clinic for Victims of Torture and founder and president of Doctors for Global Health. He explains that liberation medicine has its roots in theology, psychology, ethics, education and liberation movements. The clinic design is inter- and multi-disciplinary, community-oriented and bottom-up, risk-taking, compassionate, and uses a praxis—practice in action—model. Online resources include Social Medicine and the People’s Health Movement. In a discussion after his presentation, he stressed the importance of careful listening and action learning. He cited Daniel Levin, who was acting assistant US Attorney General when he voluntarily endured waterboarding to decide for himself whether it constituted torture. He decided it did and later lost his government job.

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