The Innovation Racket
I have excellent news for you: we have a solution to the world’s problems. Not a difficult, boring solution like fairness in global trade, curbing small arms trafficking, or improving governance. No! Our solution comes an exciting, loud package, like the toys in Cracker Jack boxes or the gadgets that used to come in 1970’s France with Pif Magazine, which was thus named Pif Gadget.
The Solution, you’ll have guessed, is innovation! I’m trying to make generous use of exclamation points, to convey the sense of excitement you should be feeling every time you read the word, or say it emphatically in a meeting room.
The Merriam-Webster dictionary defines innovation as “a new idea, method, or device”. Innovation was coined as a word around the 15th century, but in the 21st it’s become all the rage. There are dozens of funding mechanisms, some straight out called innovation, others with more modest names like “grand challenges.” There is at least one non-profit with “innovation” in its name.
What’s wrong with that? What’s wrong with coming up with new solutions to old problems, mixing it up, and using the power that has transformed rich societies, making ordering at a restaurant or knowing when the next bus is coming so much easier?
Things began to go wrong when we began to focus on the process of innovating itself, rather than on what results were being achieved. A look at the historical record teaches us that innovation has a mixed history. Some innovations have changed history. Others failed in their original form, but evolved to have an impact on society. Many others simply failed. Some prominent examples are illustrated below.
The consequences of this focus on innovation itself, rather than the results of innovation, were apparent at a recent high-profile event. The White House, which took a much-appreciated scientific, public health approach to the 2013–2015 Ebola epidemic, hosted an event called “Innovation on the Edge: Accelerating Solutions in the Fight Against Ebola”. “Accelerating” is one of several words you’ll frequently see accompanying “innovation”; others include “impact” and “scale”. A more typical title for an innovation meeting, or grant, or article, would have been: “Accelerating innovation to achieve impact at scale.” Search the web for this combination of words, and you’ll get millions of hits.
Back to the White House event, the speaker list included high-level officials and innovation luminaries, but the center of the event was an innovation fair. The overwhelming majority of the innovations on display related to Ebola treatment units: better suits, better sprayers, better tests, better drugs, better IVs, better tents.
One of the speakers was the director of research from the Ministry of Health in Liberia, who was responsible for putting together the official situation reports for the entire country. He said the two most revolutionary things at the event. First, he mentioned that the most useful innovation from his perspective was that one of the visiting expats thought to get him phone credit, which helped him in turn get data much more quickly from districts around the country. Secondly, he casually mentioned that he not been paid for the last six months.
Buying phone credit isn’t in itself innovative. Every one of the thousands of expatriates who flew into West Africa to fight Ebola expected they would have their phone communication enabled and paid for. Yet someone with a critical communication role in the response, but who happened to be from the affected country, didn’t have this basic operational support. This doesn’t reflect well on us — and by “us” I mean both the international community, and the Liberian government, either of which could have afforded the few hundred dollars it would have cost to give this person some phone credit. There’s nothing wrong with investing in technological resources, but there is something profoundly wrong about doing so without investing first in the most basic elements of any effective emergency response: communication, and local capacity.
The director of research’s second point is an even more searing indictment of our innovation priorities. Experts, decision-makers, and the media focused the public’s attention on the drama and spectacular visuals of Ebola treatment units. At the same time, almost no-one spoke of the stunning fact that many, probably most government workers in West Africa, including front-line service providers, do not regularly receive their salaries. As hundreds of millions of dollars flowed in to control the epidemic, a substantial portion going directly to the governments in charge, thousands of health workers risking their lives to save lives were still not paid. This lack of payment isn’t a detail or a side-show: Ebola in Liberia initially spread in part because the public thought the epidemic was a crisis manufactured by health workers and the government to resolve a strike related to lack of salaries. When people speak in vague terms about the “dysfunctional health systems” that set the stage for the Ebola epidemic, one of the most tangible manifestations of this dysfunction is the failure to pay salaries. At the White House conference as in the media and international public health sphere, innovation was serving to distract our attention from this vital issue.
The White House summit would have been much more useful if the innovations had focused on the issue of paying government health workers. Why do governments across Africa routinely fail to pay their health workers? Why have donors and others have been able to do so little to change this fact? All over Africa, what health workers from hospitals to remote health posts want to talk about isn’t about an app that could change their lives, or whether a three-day course of amoxicillin is as good as a five-day course, but rather: when will I get paid? Will it be the agreed amount?
It’s fine for us to be developing better personal protective equipment, but we also need to find improve the transparency and logistics of getting money from central accounts into the pockets of front-line health workers. Can cell phones help? Clever registers? A special team within the Ministry of Health? Government workers across Africa, and the people they serve, are hungry for such innovation.
To improve the situation, I recommend three questions that all of us should have when talking or writing about innovation:
1. Where’s the client? Most of the rapid improvement in user interface over the last few years are driven by feedback from users. Public health should be no different. If we checked in with our clients, which include patients and health care workers, among others, we’d quickly discover they are more concerned about things such as the availability of drugs, the cost of services, or their next paycheck, than they are about getting their PPE a little cooler. Why was the issue of salary payment so absent from the White House event? Because the organizers didn’t ask the people most concerned what they needed.
2. What results do we expect? The scale, public health importance, and plausibility of results should be presented, supported by quantitative and qualitative evidence, and scrutinized by others. It’s not enough to say, “this cooler suit will allow an Ebola clinician to stay longer in the contaminated area, and provide better care”. We need to ask: how many lives to we expect to save? Attention and investment should be proportional to impact. We might determine, for example, that getting gloves and face masks in every facility in West Africa would have far more impact than having nurses or doctors stay for twenty more minutes in an Ebola ward. In that’s the case, it should be a higher priority to innovate on supply chains than on space suits.
3. Where’s the beef? Donors, agencies, and individuals who talk about innovation should be held accountable for their results, over longer periods of time. What record of innovation do we have? How significant have those innovations been in terms of public health? Donors, agencies, and individuals who claim to be innovative shouldn’t be taken at their word. Pif Gadget itself, the French magazine bringing innovation to little French kids, was published by the French communist party, which was known as one of Europe’s most conservative –least innovative, if you will– and defended Stalinism well into the 1980’s. We have to make sure that we’re not getting store-front innovation covering for a stodgy, ineffective operation in the back.
In the present system, a “social entrepreneur” who makes bold (and in some cases incorrect) claims during a glitzy presentations has gotten over four millions views for his TED talk, and still counting, whereas the only person who presented on oral rehydration solution (ORS) in the TED universe –at a TEDx event, in fact – barely cleared 4,000 views, and not counting as it’s no longer available. The actual inventors of ORS, including Dilip Mahalanabis, Richard Cash, Norbert Hirschhorn, and David Nalin, have to my knowledge never even given a TED talk. When it comes to actual impact on people’s lives, the numbers are reversed: ORS has saved millions of lives, whereas the closest that the Lifesaver bottle to scale is a rank of 60,427 in Amazon online sales, in the Sports & Outdoors category. The introductory text to that talk claims that the “Lifesaver water-purification bottle could revolutionize water-delivery systems in disaster-stricken areas around the globe.” A more honest description, given the talk was given more than ten years ago, would be to say it “could have” revolutionized water-delivery systems. But didn’t. And that this should cause us to scrutinize the claims in that talk more closely.
Innovation has become the alchemy of today, a hugely appealing idea which has brought more attention on the alchemists than on the actual amount of gold produced. The point isn’t to stop innovating. Innovations have saved millions of lives, and can save millions more. Let’s just stop congratulating ourselves just for doing it, and pay more attention to what we’re doing with it. We should be looking at and learning from the people who developed oral rehydration solutions, ready-to-use therapeutic foods, local chlorine manufacture, and insecticide-treated bed nets. Let’s focus less on gadgets, and focus more on results.
Many thanks to my colleague Dr. Lara Ho, whose keen observation forms the basis for this blog piece
