Here's an account of using fecal transplants to improve conditions like multiple sclerosis.
(Many thanks to prosteev.livejournal.com for the image.)
No, today is not 1 April and I'm not joking.
Research shows that bacteria in feces make a big difference to the state of health of the body. Transplanting samples from a healthy bowel can rebalance an unhealthy gut.
Once again research led to a plausible innovation in treatment. A bigger hurdle was to challenge traditional notions that all crap is dirty and should just be flushed away.
An Australian maverick gastro enterologist, Thomas Borody, treated William Kostopoulous with satisfying results. His colleague, Alex Khoruts, at the University of Minnesota, also worked with this approach to treating disease.
Marc Koska invented something to make an impact on the rapid spread of HIV and AIDS through re-used syringes:
'My motivation was half humanitarian and half wanting to see whether I could do it. I never set my sights on a Ferrari and I never wanted to be Joan of Arc; it was somewhere between the two.'
He read an article in 1984 about the problem and spent 27 years trying to invent and bring to market a device that could change the growing loss of life in the developing world. Marc devised a single use syringe.
Here's a man with A levels, who spent part of his time as a beach bum and then took casual jobs to keep himself going. The process was tough and there's little margin in selling syringes, so it was difficult to market the product initially.
'I think our product has won out because we didn’t set out to design the best syringe in the world – I designed it to be adequate and very easy to manufacture.'
Marc decided on 3 design pillars for the new syringe:
1 Make it on existing machines (with the same plastic)
2 Sell it for the same low price
3 Ensure it's used in the same way as existing syringes
His TED lecture includes examples of children recycling and selling old syringes or playing with syrings with traces of blood in them:
Who inspires Marc to keep going?
'I could have given up a number of times. I was offered quite a lot of money for the project before we even sold any, and I said "no" because it was likely to be killed at that point. The only person is the one that you look at in the mirror.'
This story highlights 2 distinct issuesin developing innovations.
1 How to devise, manufacture and sell something the market needs and can use at a price consumers are willing to pay
2 How to ensure that the product or service is adopted, so that it becomes ubiquitous
Marc is aware that safe syringes will only be used when consumers demand them as standard. This is difficult in developing countries, where patients may not challenge doctors, who have high status. He noticed that his syringes were being used in one part of a Ugandan hospital, but conventional syringes were re-used in another part.
In 2008 'After the gruelling five-day media blitz in the country in November, Mr Koska said he was able to return for a meeting with Indian health minister Dr Anbumani Ramadoss in December and leave with the guarantee autodisable syringes would be used in all public hospitals and clinics starting in April this year.'
There is no let up. The fight for basic healthcare in developing countries is tough and takes great persistence.
"When the minister said 'yes' I went outside and cried for five minutes."
The UK National Health Service is based on a military model of organisation. In the 1970s Monty Python devised a sketch that parodied the hierarchical organisation and tendency to infantilise patients. I remember the key lines as: 'Me doctor, you patient. Me expert, you idiot.' This clip shows that the second line is a figment of my imagination, though the tendency to assume complete ignorance amongst patients was accurate at the time:
Writers on empowerment and culture change, such as Bowen and Lawler, tend to suggest that managers are responsible for bringing about change that benefits customers by various initiatives.
If we take a systems view of organisations, it should be possible to bring about change in the whole system by introducing a variation in one part of it, so that everything else adjusts to come back into balance.
Peter Senge focussed on a US health example in 2010 at the Systems Thinking in Action Conference:
This clip shows Russell Ackoff discussing US healthcare and the split between theory espoused and theory in practice:
In the 1990s Glaxo Wellcome made a strategic decision to shift its marketing effort away from the usual custom of giving desk ornaments, equipment and stationery to general practitioners as a way to encourage them to prescribe GW drugs. Scenario thinking indicated a growing discontent amongst some doctors at the way pharmaceutical companies operated as well as concern amongst the public at the idea of bribing doctors for profit. Impact on prescribing was declining and local coordinating bodies were considering ways of reducing costs by recommending the use of generic, cheaper alternatives to branded medicines.
Glaxo Wellcome trained practice nurses to become specialists in dealing with a small range of diseases (such as asthma and diabetes) and learn how best to monitor and adjust medication. This altered the position of nurses within primary care and was one of the catalysts for the introduction of nurse prescribers, which was useful for district nurses and others who could not rely on easy access to a doctor to issue a prescription when doing home visits. Pressure was applied to upgrade nursing training and ensure that all nurses had degrees. A split emerged, particularly in hospitals, between those who did menial tasks and hands on care work and those who sat at computers, undertook medical procedures and dispensed medicine.
Some aspects of the supply chain were challenged by new providers. Tesco started offering prescription chemists in large supermarkets, which was especially welcome to Sunday shoppers. Both opticians and dentists were challenged by large corporate chains and Vision Express and Specsavers came to dominate the optician market. This introduced more flexibility, choice and some lower prices to consumers. New models of payment and insurance further changed the market, with Denplan making waves in dentistry.
The growth of the internet and freely available information led to the arrival of the 'WikiPatient', who would turn up to a consultation carrying a thick bundle of documents printed from the net. Doctors might dismiss this as information overload, quack alternative medicine or populist misinformation and tell patients either that they risked becoming a hypochondriac or simply "Trust me, I'm a doctor". However with freely available peer reviewed scientific abstracts and full articles available through PubMed, these arguments began to seem lame.
Intelligent lay people in the US have access to medical education, which, in some cases has gone viral globally, for example Dr Robert Lustig's entertaining lecture on high fructose corn syrup:
Politicians also influenced the NHS. Margaret Thatcher was a champion of free markets and impatient with silos and closed shop agreements amongst professionals, which restricted who could do a particular job. She challenged the distinction between barristers and solicitors and allowed solicitors to represent clients in court. Doctors and consultants recognised that Thatcher had them in her sights and that they could not retain exclusive access to certain work. The new GP contract introduced by the Labour government was an attempt to gain more flexibility from doctors, but resulted in added costs for evening cover.
Subsequent governments have introduced Choose and Book which ensured that doctors and patients decided together when and where a patient would receive secondary and tertiary level treatment. Patients now have the choice of a GP centre wherever they wish, not restricted by a catchment area. Wikipatients, who discover their doctor resists entering a collaborative relationship in caring for their health, can now easily vote with their feet. They also have the right to view their notes and specify if they want to allow open access to the information on the NHS Spine or opt out of the system.
Burgeoning consumer choice and experience of rapid service from the likes of Tesco, increased pressure on doctors from patients who might, for example, demand an obscure treatment with Mongolian goat serum costing £100,000 for their rare foot disorder free on the NHS.
Diabetes care is one example where there was pressure from all sides to introduce home monitoring equipment. Inverness Medical pioneered glucose monitoring strip manufacture in the UK and now glucometers are in widespread use and can be purchased without prescription. The combination of busy lives, lack of time to go for health checks and the cost of nurses' time in doing simple tests was one driver, as well as increasing demand from patients for control over their own lives and accurate information on which to base choices. At the same time compact, portable devices for testing and treatment were developed for use by ambulance paramedics, oil rigs, armed forces and astronauts, where easy access to doctors and hospitals was limited and costs and consequences of non-treatment were great. Manufacturers have understood the trends and marketed similar devices to professionals and the lay public.
Dr Bernstein was a US engineer who took charge of his own health and reversed major side effects of his diabetes. No one would publish his results and he trained to be a doctor so that he could help other diabetics who were getting worse.
Some doctors are rebelling from within. Dr Malcolm Kendrick challenges current orthodoxy about cholesterol. This video is part of a series where he presents evidence to medical colleagues:
Some patients are bounding up Professor Mick Marchington's stairway of empowerment from consultation, to codetermination and towards a measure of control, whilst many are standing on the bottom two steps, satisfied with information and communication.
Doctor education now includes a significant amount of time devoted to communication skills, including an element of role play assessment, to test how trainee doctors deal with patients in a range of situations.
Not all doctors or consultants are happy with the pace and type of change. Some continue to challenge patients who show evidence of knowledge or involvement with their own healthcare. As Bowen and Lawler assert, Theory X managers find it harder than their Theory Y colleagues to adapt to the pressures applied by patients. Some find it tough to work with patients who are passive and waiting for the doctor to fix everything without their active collaboration.
The spread of ambulance chasers and recourse to the law to resolve complaints has the potential to make relationships more adversarial, though some doctors claim that the more they involve patients, the fewer complaints they receive.
Managers have played their part in empowering staff and patients, but change has been introduced into the system from other parts of the supply chain and external organisations.
Clay Christensen talks here about future opportunities for disruptive innovation and starts with healthcare:
Edgar Schein has some wise counsel for young managers attempting to make rapid changes to the culture of their organisation:
'People often talk about changing their corporate culture and building a “new culture” within their organization but can you imagine trying to change the culture of the United States or France? Whether your organization’s history is long and stable or short and intense, its culture is complex and deeply ingrained in its people and operations. In order to successfully effect change, corporate culture must be taken seriously. Examining it at all levels uncovers the assumptions that determine the organization’s goals, strategies, and means of action. This knowledge is the stepping stone to promoting change within your organization.'
Dr Fons Trompenaars helps clarify culture in vivid terms:
He then contrasts this with corporate culture and provides some tools to help us analyse our own organisation:
Ricardo Semler took over the family firm, Semco, in Brazil fired with enthusiasm for a range of management fads. After a heart attack and major setbacks he began to find a different way by harnessing the enthusiasm and ability of his staff. This recognised the diversity and self organising capability of teams. The risks were outweighed by the benefits of an explosion of energy, inventiveness and flexibility. The change took a long time and involved a number of wrong turnings and setbacks:
Not everyone has the appetite for such a fundamental change.
Dancing Fool was a song by Frank Zappa from Sheik Yerbouti. In it he describes dancing off the beat and committing social suicide on the dancefloor.
Ricky Gervais portrayed the manager as dancing fool in the UK tv series, the Office. A number of managers and consultants confessed to hiding behind the sofa when it was first shown, because it was excruciatingly true to life.
Jim Collins and Henry Mintzberg describe some of the antics of leaders as bizarre and idiosyncratic and do not subscribe to the idea that charisma and larger than life personalities contribute anything positive to leadership, despite the media hype.
Both of them bemoan the elevation of leadership to mythical cult status, whilst management is relegated to a tedious support role, judging by the ratio of books about these topics on sale.
Followership is little known, valued or understood.
This video takes us back to Zappa with interesting comments on how leadership is made.... by its followers:
This is the Dutch view of MBAs, according to Dr Fons Trompenaars.
Henry Mintzberg is scathing about conventional full time MBA programmes based on case studies:
'“The MBA trains the wrong people in the wrong ways with the wrong consequences” Mintzberg writes. “Using the classroom to help develop people already practicing management is a fine idea, but pretending to create managers out of people who have never managed is a sham.”
Because conventional MBA programs are designed for people without managerial experience, they overemphasize analysis and denigrate experience. That leaves a distorted impression of management, which has had a corrupting influence on its practice.
Leaders cannot be created in a classroom. They arise in context. But people who already practice management can significantly improve their effectiveness given the opportunity to learn thoughtfully from their own experience.'
He recommends that young people get jobs, work their way up to management positions and then study for an MBA that draws on their own practical experience. Case studies, such as Semco, are fine, but only as an adjunct to students' own practice. In this video Ricardo Semler discusses his experience with Mintzberg of being wheeled out like a zoo animal in front of MBA students (with an invisible sign: Do not feed the businessman.)
Guy Claxton studies thinking and how we develop intelligence. He has focussed on schools and the idea of building learning power for use in any context. That, rather than remembering a load of facts, is the aim of education. Learning to learn and use this as a flexible tool for life is the fundamental purpose of both schools and well crafted MBA programmes:
Jim Collins uses this term in crediting Peter Drucker's influence on some of the most famous innovative companies such as Hewlett Packard, an organisation built on values.
Drucker did not follow the tendency to make a Procrustean Bed from theory, fitting the data to what had been proposed in abstract. He began with empirical data based on the observation of people and organisations in practice and then reflected on the role of organisations in the evolution of society at this stage of human history.
One distinction Collins makes is between the tendency to answer questions of increasing irrelevance with increasing precision and Drucker's courageous drive to ask questions of increasing significance and find answers with increasing empirical rigour.
Collins takes the view that the overriding question is 'How do we make society more productive and more humane?'
If you build great, well-managed companies and destroy human beings in the process, this would be a failure.
Collins discloses how his team of young, sceptical students challenged his ideas and pushed him into research on Level 5 leadership.
Collins challenges received notions of underprivilege used to explain poor success in society, citing examples of level 5 leadership enabling people to triumph over adversity.
In scenario thinking he uses the metaphor of climbing a mountain to describe our present state in a world of ferocious change. We are climbing at 20,000 feet in a storm and far from base camp. Collins believes we will return to prosperity, but not stability. The storm may pass, but there's no return to base camp. Developing countries have long experience on the side of the mountain and are better skilled than we are in dealing with this environment.
One of the challenges for rising generations is in dealing with change and restriction over time, without expecting rapid development or a speedy return to better conditions.
He quotes Admiral Stockdale's account of time spent in a Prisoner of war camp in Vietnam and his claim never to have been an optimist during that time:
'When you're imprisoned by great calamity, great difficulty and great uncertainty, you must never confuse the need for unwavering faith that you will find a way to prevail in the end and the discipline to confront the most brutal facts we actually face.'
When I first started in consultancy, one of the books that inspired many business people was 'In Search of Excellence' by Peters and Waterman.
IBM was featured as one of the successful companies and held up as a great example. Big Blue along with others in the book then declined, whilst the fortunes of Microsoft rose.
Critics sneered at the 8 themes parodying the book as 'In Search of Stupidity'.
I noticed that business people liked the simple, memorable formulations and clear descriptions of how best to proceed. They were more likely to apply the 8 practical themes than more sophisticated academic theories.
In the years that followed I also met IT professionals who worked for IBM. Some described themselves as cube dwellers in the style of Dilbert.
Others told me something fascinating. IBM dealt with the disruptive innovation caused by personal desktop computers and faded from view. The company continued to operate, but in a different way. I learnt of a web like network of small companies that fed into the mycelium of IBM, enabling Big Blue to tackle new frontiers with the power of the giant and the agility of Jack and the beanstalk.
Henry Chesbrough uses IBM as one of his example of Open Innovation.
That'll surprise the people jeering from the peanut gallery, but not me.
An article by Elizabeth Day caught my eye as it describes a practical example of innovationadapted to local culture and conditions, empowering people with lowest status and resources.
Dr Abhay Bang and his wife, Rani, have worked for 26 years training local volunteers in Gadchiroli, a deprived district of Maharashtra, India. The idea was to treat simple health problems at home. The volunteers are called arogyadoots or Health Messengers.
Results are impressive: newborn death rate has fallen from 121 to 30 per 1,000 live births. In 1988 the death rate among children who developed pneumonia was 13%, now it has fallen to 0.8%.
The mission of their charity, Search (Society for Education, Action and Research in Community Health) was to listen to the people and find outwhat kind of healthcare they wanted.
'"We are very MUCH part of the community," says Dr Bang, ...."I really can't say where the line of separation is between them and me. It is research with the people, not on the people."
Cultural differences derailed efforts by NGOs to impose western models of healthcare on rural India:
'"The villagers said they were scared to go to hospital," he says. "When we asked why, they told us something fascinating. They said: 'Your doctors and nurses drape themselves in white clothes. We wrap dead bodies in white shawls. How can you save lives if you are dressed like a dead person?' They said: 'When they admit a patient, we can only visit between 3pm and 6pm and we don't have wristwatches. We don't have anywhere to stay in town, so we go back to the village. The patient doesn't want to stay on their own."'
Dr Bang ran People's Health Assemblies to consult people on their most pressing issues in healthcare and heard about the high rate of death amongst newborn babies. Local women were then trained in low tech ways of managing neonatal care and went where they were needed using portable health packs. The Health Messengers passed on their knowledge and whole communities became empowered - from consultation, codetermination to control.
He also constructed a hospital that resembled a local village so that patients could stay with their relatives. This shifted a sense of ownership to the local community.
The innovations were driven by local demands (market pull) and the increasing availability of portable tools intended for outreach care (technology push).
Dr Bang was motivated to help by the story of a young woman who arrived too late for doctors to save her baby. She related the practical challenges she faced in coping with isolation, a drunken husband and travelling to the hospital. Rather than feel overwhelmed and give up because of the enormous size of the problem, Dr Bang reflected from a systems thinking perspective:
"But then I looked at the whole situation and asked myself: 'Do I really need to solve all the problems, all the links in the chain of this cause of death?' I started to think: 'Where is the weakest link I can attack?' and that was access to healthcare." He falls silent for a moment. "It was practical compassion, not a flash of genius."
Dr Bang and his wife also campaigned successfully for a ban on alchohol in Gadchiroli district to reduce some of the problems contributing to low income, fractured families and poor health.
I hadn't heard the term hacking used in relation to repair and customisation of products until I was introduced to the work of an Irish woman called Jane.
Jane used the Bug Listing technique to identify broken, awkward and old things that she'd like to reclaim, rather than throw out to buy new replacements. She involved 2 material scientists, Ian and Steve, and devised a product called Sugru.
Like Steve Jobs, Jane also believes in empowering people through technology, but in her case by something small and low tech.
Photographers are one group who have tested Sugru in extreme conditions and found it worked well.
Scott Anthony & Clayton Christensen wrote extensively about the impact of disruptive innovation on companies that failed to predict change or adapt swiftly to it. This video presents a clear analogy.
They devised a 3 part process to help improve crystal ball gazing called 'Seeing What's Next.'
The first part focusses on the needs of 3 sets of customers: the overshot, undershot and nonconsuming customers.
Sugru resembles other products such as Blu Tak, Polyfilla and Mastic filler. Undershot customers find these solutions too weak, too rigid, insecure and uncomfortable for their purpose. Each bug that Overshot customers identify may have a specific fix, supplied by the manufacturer, such as a camera mount, but this can be unsatisfactory, tricky to use, too fancy or too expensive. Nonconsuming customers may be people who give up and throw out the equipment, because it doesn't work satisfactorily or seems irreparable.
Sugru enters the market through viral marketing by specific groups of Hackers. Time will tell whether it grabs the largest slice of the market from other 'fixers' and undermines sales for costly, niche adaptor products.
What it has done is focus on the purpose the customer has for a product, or 'the job the customer hires it to do', as Christensen says, no more and no less.
Someone has already creatively swiped the idea and made their own adaptation for fun objects and circuit board applications.
Steve Jobs likes to empower people through technology.
'Let's say that -- for the same amount of money it takes to build the most powerful computer in the world -- you could make 1,000 computers with one-thousandth the power and put them in the hands of 1,000 creative people. You'll get more out of doing that than out of having one person use the most powerful computer in the world. Because people are inherently creative. They will use tools in ways the toolmakers never thought possible. And once a person figures out how to do something with that tool, he or she can share it with the other 999.'
Steve Jobs developed Pixar Animation, famed for Toy Story, Monsters Inc and Ratatouille. He probably didn't imagine that the iPad would be used to develop light sculptures and a different use of stop motion animation. We are familiar with stop motion from Wallace and Gromit and plasticine characters.
Welcome to the world of iPad light sculpture, developed by Dentsu with the same technology, but a particular software.
Steve Jobs was referring to ordinary users of his products, rather than employees, who often have to seek permission to do something radically different in an organisation. Where creativity and innovation are possible, managers shift from a supervisory to a facilitative role in nurturing their team's creative work.
Scott Anthony writes about how to spot disruptive innovation opportunities. Often it's not a difference in product but business model that changes the game:
One user said this about the iPad as a game changer:
'The iPad only does less than a regular computer to us geeks. To everyone else, it does more. This is what Motorola and Google and Samsung and BlackBerry and everyone else, with the sole exception of Apple, do not get about “open” computing'.
That's the gloomy view of some forecasters in the UK. We hear daily reports of job cuts and business bankruptcies.
I find it interesting to listen to other voices, beyond the mass media and Opposition party politicians.
One City Trader has been saying for some time that business debt is being closely managed and that figures for the economy are all improving. A BBC radio 4 programme gathered together senior business people who seemed to agree with this view.
All of the business leaders said that they'd avoided cutting staff. They agreed on some simple rules for success: Look after your cost base and re-structure in the good times, but don't cut in a recession if you can avoid it. You'll need good people to take advantage of opportunities as the economy starts to recover. It's more expensive if you cut and then rehire.
Part of the discussion centred on the rapid progress of Germany out of recession and considered how their manufacturing base has done so well.
Collaborative approach to business between management and labour unions was one of the factors mentioned, along with medium sized businesses that focus on a single niche product. The overriding factor seemed to be the rapid move into global selling. This was contrasted with the British norm: first establish a firm market in the UK and then consider expanding overseas.
How do you get people to listen when they have shunned you in the past?
One old soldier did it by persuading Peter Kosminksy to make a film about the work of his colleagues in Palestine during the Mandate after the war:
'The letter was from an old soldier. Complimenting our programme about peacekeeping in Bosnia, he asked us to consider making a film about an earlier peacekeeping effort in which he had played a part. A hundred thousand British soldiers had been tasked with holding the line between the Arabs and Jews in Palestine. Within three short years this mighty force was hemmed in and harried by a tiny guerrilla band of Jewish insurgents. Exhausted and demoralised, the soldiers returned home to find that the nation wanted nothing to do with them. No memorial was erected to mark their campaign; he and his fellow Palestine veterans were denied the right to march to the Cenotaph in formation. Their apparent defeat at the hands of a rag-tag force of amateurs had sullied the reputation of a British military still basking in its victory in the Second World War. Like Vietnam veterans in years to come, they found themselves shunned, their struggle quickly forgotten. Would we consider making a film about those three arduous years, to set the record straight?'
The result was shown on Channel 4 over the last 4 weeks and is well worth watching.
The film attracted a lot of criticism from Jewish commentators. Here is part of an interview with Al Jazeera, which includes criticism and support from a Jewish audience:
