What is a Social Business?

Nobel Peace Prize laureate Muhammad Yunus (also the Commencement speaker for Rice University’s Class of 2010) proposes a new concept for business, called a “social business” in his recent book, “Building a Social Business.” He argues that social businesses are especially relevant in our world dominated by capitalism, as they integrate the productivity and efficiency of profit-making business towards truly making a positive, social impact. I have been reading his book, and I have absolutely fallen in love with this concept of social business, and its implications for helping humanity.

These are the Seven Principles of social business according to Yunus:
“1) The business objective is to overcome poverty, or one or more problems (such as education, health, technology access, and environment) that threaten people and society- not to maximize profit.
2) The company will attain financial and economic sustainability.
3) Investors get back only their investment amount. No dividend is given beyond the return of the original investment.
4) When the investment amount is paid back, profit stays with the company for expansion and improvement.
5) The company will be environmentally conscious.
6) The workforce gets market wage with better-than-standard working conditions.
7) Do it with joy!!!” =)

The problem: the dependance of Malawian people on expensive fertilizer.

Malawi has a primarily agricultural economy. Thus, the main source of income and food for the majority of Malawians come from cultivating crops such as corn (for their starch staple of nsima), soya, ground nuts, tomatoes, and other vegetables. Unfortunately, the soil here in the Namitete region is not very fertile; hence, fertilizer is necessary for any growth of crops. Because the fertilizer is mostly imported from outside of the region, it is expensive and often out-of-reach for many Malawians, especially those suffering from sickness and stigma from HIV. Local political corruption has prevented the implementation of government subsidies of fertilizer in the form of coupons from reaching many Malawians.

When Tiffany and I visited many HIV support groups in the region, their main challenges included malnutrition, lack of secondary education (which is not free in Malawi) for children, and lack of stable income. Many of these HIV support groups were attempting to pursue an agricultural form of living, and St. Gabriel’s Hospital has been trying to help them by supplementing piglets, seedlings, and other relevant materials. However, again and again, we found that support groups were struggling to cultivate crops due to the prohibitively expensive cost of fertilizer.

Therefore, I suddenly thought, “why not create a local, social business developing affordable fertilizer for the area as a means of bringing the region out of poverty and boosting local productivity and economy?”

Potential solution: a social business for locally and sustainably produced fertilizer employing St Gabriel Hospital’s HIV support groups and community health volunteers

The idea is to produce fertilizer in an affordable and sustainable way to help bring the region out of poverty. Inability to purchase fertilizer due to its expensive cost coupled with lack of savings for the September and October “starvation period” are important contributors to malnutrition. We plan on encouraging sustainable business practices at an individual and HIV support group level through the implementation of microenterprise seminars. However, even with adequate saving skills, the expensive cost of fertilizer still represents a formidable barrier.

Thus, what if a social business were created to not only employ these HIV support groups and community healthcare volunteers, but to create fertilizer in a sustainable and affordable fashion? Would it be possible to produce an alternative substantially more affordable than the current fertilizer that is just as effective? Can we make this a sustainable business that will distinguish the Namitete region and bring in business and income from the rest of the agricultural industry in Malawi?

Tiffany and I have spoken to Alex and Angela of St Gabriel’s Hospital, who are both constantly in the field interacting with both HIV support groups and community healthcare workers. They both really like this idea, and think that it has much promise. We got some contact information for some schools of agriculture in Lilongwe (the capital city), so we hope to seek out advice to see if this idea is even viable.

I recognize that this is a huge undertaking that might not even work out. But the least we can do is do some initial research and perhaps deliver a business plan proposal to the leadership at St Gabriel’s to make them aware of such an option.

 

[June 17, 2010]

With permission from the Matron, we took BTB’s hand-held centrifuge device, developed by Lila Kerr and Lauren Theis, to the Antenatal ward this morning. We met with Gift, the worker who takes blood samples from pregnant women and tests for HIV, anemia, and syphilis (although they are currently out of the syphilis reagent and cannot conduct that test at the moment). After explaining how our device worked, Gift appeared very excited to try out the technology. We took this as a great sign, and immediately got to work.

He called in patients one at a time, and we decided to start easy – with 5 samples for the first run, then 10, and then 15. Knowing that Sally is accurate to 10%, we cautioned Gift that the device was not to be used for diagnostic purposes, and simply to get feedback. Nevertheless, as we started to fill the combs, pump the spinner, and make the readings, I could see the anticipation grow and the desire to give patient recommendation for the device.

A few notes on the centrifuge: I think a better numbering system could be put in place. Aside from the fact that the Sharpie-marked numbers 1-5 were easily rubbed off when cleaning the spinner after use with alcohol, as we began to fill the combs with more and more samples, we had to mentally keep track of which capillary tube belonged to which patient. We decided to give subclassifications A,B,C, etc. to the multiple samples in the 1^st comb, then 2^nd comb, and so on, but it would be nice if such a system were already (permanently) marked. Another suggestion was to change the color of the bottom plate. Red looks nice, but makes it difficult to see any potential blood spills and splatters during the cleanup process.

Tomorrow will be another visit to the Pediatric ward to test out Sally. As for now, I’m happy with the feedback from this first trial and am excited that we’ve already gained some ground on our projects.

[June 15, 2010]

I have never been the best at picking up new languages. Even after one week and multiple introductions, I still become flustered when Sister Annie, Sister Justa (the hospital chaplain), or one of the nurses asks me in Chichewa, “Muli bwanji? (How are you?).” I respond with a timid “Dili brino, calle inu? (I’m fine, and you?)” and wait for their similar answer of “Ndiri bwino.” The language barrier presents a challenge and I’m sure that my Chichewan-struggles are providing the native Malawians here with a source of entertainment. But I gladly play along, happy to see that I have brought some laughter to their busy day.

It has already been one week since we arrived in Namitete! Time seems to fly by. This afternoon, Jasper, Liz, Yiwen, and I met with Matron Kamera (our mentor and head nurse of St. Gabriel’s) to once again introduce ourselves and our technologies. Loaded with our goodies in hand, we briefly took her through each technology as she directed us to the appropriate wards to implement them and acquire feedback.

In the middle of it all, I suddenly felt worried that we were bombarding her with all of our exciting projects. Sure, it seemed like a reasonable list throughout our packing and planning process, but perhaps the combination of me and Jasper’s projects and technologies with those of Liz and Yiwen’s may have been overwhelming. I’m sure we were all thinking the same thing: the Matron is extremely busy, so this might be our only chance to sit down with her to discuss everything! However, looking back on it now, the four of us probably should have set some technologies aside, like the demos and donations, or grouped our technologies into a more manageable batch.

Nevertheless, this meeting gave us the green light to bring our technologies into the wards. More importantly, it gave Jasper and me some new developments in our Microenterprise Program.

Since the first assignment in BIOE260, our project has gone through a few transformations. What began as a microenterprise education course designed for community health workers selling PUR packets and ended as a seminar program establishing trust groups amongst the workers, our general focus has always been microenterprise, but with varying contexts. Well, our context is shifting again, and the newest revelation assigned by Matron Kamera is now to help teach microenterprise skills to promising HIV/AIDS support groups. As part of their partnership with St. Gabriel’s, these groups are given community starter packs to help families establish businesses. These starter packs may include seeds, fertilizer, tools, or even goats. The problem is that most groups do not understand how to think in the long-term – save, budget, create a business plan. This is where we would come in.

Apparently, there has been one successful community that has really grasped the idea of the starter pack. If we can model their success into an appropriate business plan for other communities, I think we can achieve the goal of implementing microenterprise in the villages around St. Gabriel’s and really help establish a steady source of income for the people in the support groups.

Ah, the importance of being adaptable! Just like we were advised throughout the semester and reminded again at orientation, you never know what will happen in the field. Luckily, we’ve had some experience with being flexible in our project, and I’m sure we’ll be able to modify our microenterprise lesson plans according to their needs. I’m actually really excited by this turn of events, knowing that this is what happens in real life!

June 16, 2010
Well we are still having internet issues here in Namitete. Yiwen and I will go into Lilongwe on Saturday to post this, and other blogs. It is very challenging not having internet or easy phone communication. I feel disconnected and more homesick than I have ever felt in 21 years of life, however, these feelings aren’t too severe and definitely not enough to distract me when at St. Gabriels. We finally got to meet with Matron Kamera. All of us discussed our technologies with her in turn, stating their intended goals, how they work and then asking where she saw them being most useful.
The hot cot electronics controls might be useful, but as it is missing their special thermostats right now, it is not very functional. The hot cot crib built by Elizabeth Nesbit and Yiwen when they were here last year still works and its use has been recorded about 4 times in this past year. It is kept in the “kangaroo room” which is a special room, with two kangaroo nurses, that is kept very warm. The kangaroo method is a way of keeping premature or low birthweight babies warm. The mother holds the child continuously to her chest in a warm environment. It helps maintain body heat through skin to skin contact, encourages breast feeding, neonatal health and mother-child bonding. It is a fairly new “method” and is popular for low resource settings because it requires little technology or direct cost. The incubator seems to be used much less than the kangaroo method here at St. Gabriels.
Yiwen and I were able to clear up a little confusion surrounding the use of the current incubator with the kangaroo nurses. The number or lightbulbs turned on is directly related to the temperature of the cot. If you get a child, you must look up on a table, its weight and age to determine the necessary air temperature in the cot. Then you refer to a table which says how many light bulbs you use to get that air temperature. They weren’t following this method, but we were happy to learn, that the nurses attentively monitor the baby’s skin temperature when in the incubator for safety. In any case, the nurses always use all 4 bulbs, the warmest setting. This made sense considering the tiny weight of the children, some less than 800 g (less than 1 lb). The electronics for this cot that we brought would help remove both the problem of choosing the right number of bulbs (by only allowing all 4 to be turned on) and would only allow a high and a low temperature setting, chosen based on the discretion of the nurses. Then they could be sure that the air temperature was indeed the temperature selected by the electronics. I hope to show the box to some of the pediatric nurses soon to get feedback.

June 17, 2010
On Thursday, Yiwen and I went with the “mobile clinic” nurses to a village called Dzama, 19 km (about 10 miles) from St. Gabriels. We hopped in the back of the pick-up truck with two nurses, and drove, slowly, though the countryside and small collections of houses over the bumpy red dirt road. With us we took syringes, a mechanical scale, immunizations, a blood pressure cuff and some record books. Along the drive we pick up a few more community health care workers.
Once we got there, we were greeted by a long line of mothers, all either pregnant, with their small children or both, standing outside the school house. (school is only Monday –Wednesday here) My job was weighing all the pregnant mothers on the scale and recording their weight in their “health passports”; yellow books especially for womens health, with sections for general health, family planning, ante and post natal checkup etc. Other things done that day were providing DPT (diphtheria pertussis and tetanus ) vaccines, weighing children to see if there are malnourished. All the pregnant mothers went to a back room for further exam, I don’t know what of.
Some babies on seeing me, especially if I waved at them, would turn towards their mothers and cry. A few even called out “mzungu” (foreigner) in fear. Most however are quite and curious. After all had been treated, I stepped outside to see a small crowd of young girls. I walked toward them to offer my hand for a hand shake, and it took awhile for a few to be brave enough to shake my hand. Soon though, with the help of some interpretation, I was teaching them how to play “red rover” and “duck duck goose.” Mothers gathered around to watch us. After games, the girls taught us their dances, and Yiwen and I danced with them. I bet we looked pretty silly but everyone was having a good time.
The pregnant mothers ranged in weight from 41 kg (90lbs) to 80 kg (175 lbs), however, this last mother was a bit of an outlier from the whole group. Almost all of the mothers were shorter than me, at my medial 5’7’’, even when they were standing on the scale. It seems like many of the women here are smaller in stature. It is difficult to tell if they are underweight because of the layers and layers of fabric they wear. Perhaps their smaller stature arises from consistent malnourishment, which is a problem here. When we were driving through the countryside there were many “feeding programs” organized through schools and some of the pediatric patients come in with little fuzzy orange-ish hairs on their heads, which, I think, is an indicator of malnourishment.
Malnourishment is an interesting problem that presents in all societies, even still in the overfed US. In medical anthropology, our class discussed some theories of malnourishment and there are even some, although not well respected scientists, who argue it is not detrimental to development. Here though malnourishment puts people and much greater risk for infection from things like a common cold to HIV. It creates a vicious cycle of malnourishment, weakened immunity, infection, increased caloric needs which in turn, exacerbates malnourishment.

———-
On Friday we tested the oxygen concentration sensor that was brought last year. It still worked well with both machines used in pediatrics to concentrate the oxygen. The technician says they use them about once a month when they are doing their routine checks of the oxygen concentrators. Since the O2 cartridges still seem to be working pretty well, we just showed the techs how to replace them once they start to perform less well. We are giving them a card with instructions on how to tell when it is going bad, how to replace the cartridge and how to recalibrate the sensor if necessary.

[June 8, 2010]

After 5 months of project preparation, 4 weeks of planning and packing, and 40+ hours of commute (including a layover and short rest in a Yotel in London), I’ve finally arrived at St. Gabriel’s Hospital in Namitete. Whew!

So far, I feel like I’ve only had a glimpse of Malawi: A car ride from the airport in Lilongwe to the St. Gabriel’s campus showcased the beautiful landscape and terrain. A trip to the major supermarket, Shoprite, in Lilongwe presented the bulk of my food supply for the summer. The drive up to the hospital entrance displayed the neighborhood goats, chickens, and bike taxis for transport. A wander into the village market introduced me to the curious and friendly people of this culture. And St. Gabriel’s? Well…

On our first official day, Jasper and I met with Sister Annie, the head nurse of the pharmacy, who took us on a mini tour of the hospital before ending up at the ART (Antiretroviral Therapy) Clinic for our first assignment: counting and packing pills that would be distributed to HIV/AIDS patients. – Perfect! Here was a great opportunity to test out our pill-counting device!

Little did we know, the office already carried two previously donated digital scales (with weighing boats to match), so we actually ran a little comparison test. Using similar ‘measure to desired amount-tare-fill to accurate read’ techniques, we found major differences in use. The digital scales had greater weighing capacity, greater carrying capacity, and, after multiple trial runs, better precision and accuracy. Unfortunately, our diamond scales were not equipped to handle the size and high count of pills necessary per packet. So, it’s smaller weighing and carrying capacity served as a disadvantage. Alas, the problem with the digital scale was proven by the dead battery at the end of the day, so a point to our diamond scale for that criteria!

After finishing a carton of the medicine, it was time to close up and my mind was seeing spots approximately the size of the pills we just packed…

With perfect timing, soon after we got back to the house, Liz and Yiwen arrived from the airport. We had a really laidback evening, and after some home-cooked food (which still has a lot of room for improvement) and good company, I was exhausted and ready for my mosquito-netted bed.

We had an opportunity to go on our first mobile clinic this week, to the farthest post no less, a village call Dzama. It is about 19 km from the hospital, which driving over unpaved, dirt roads, translated to 45 minutes of  a very bumpy car ride. We left around 8 in the morning to arrive eventually at a school house to a long line of already waiting women, pregnant or with children. While it was impressive that the hospital makes an effort to reach villages as far as possible, it is noteworthy still that some of mothers had to walk 5km to get to Dzama.

There are two separate procedures for pregnant women and women with children under 5. For pregnant women, they first need to be weighted and the number is then recorded in their health booklet. The mobile clinic offers tetanus immunization for the mothers, so if they need it, they then go to the immunization station. All pregnant women are tested for HIV using the RAPID test that yield results in 15 min. St.Gabriel’s is very active in PMTCT and if the mother is discovered to be positive, she is referred to the hospital for counseling and treatment. As I rotated amongst the stations, I was surprised that at the immunization station, we had a supply of syringes that are automatically set to certain volumes to prevent an overdosage, sort of like the dosing kit we brought.

For the mothers with under-five children, they are first lined up outside beside a tree where their babies are weighed. The method is a little awkward but fast; normally, the children are slung on the mother’s back in a backpack fashion. To weigh the children, the sling is shrugged off and then hooked onto the scale hanging from the tree, like weighing a pack of meat. The weight is then tracked on the health card that has a trajectory indicating the ideal range of weight the baby should be at certain ages. Extremely malnourished babies are counseled and referred to the hospital. Children are also given the polio, DPT and measles vaccinations in addition to the oral administration of BCG.

The services offered are obviously very basic, but they are focused on two important factors impacting fetal mortality in Malawi. Vaccinations are the most cost-effective global health intervention while PMTCT is essential in ensuring the health of all babies given the relatively high HIV rate in Malawi. Traveling on the road to this remote village, the landscape really gave a perspective of how hard it is for healthcare to reach the entire population of Malawi. There are small villages, usually made up of a circle of huts with bricks and thatch roofs, scattered kilometers apart. Everyone is either riding bicycles or walking; there is no sign of paved roads or cars. On the way back, we picked up mothers on their way walking to the hospital on a journey that would take a car 30 minutes to travel. Malawi is truly still a very rural country, which makes even the simplest intervention like the services offered by the mobile clinic important and of high-impact.

Meeting with Matron Kamera definitely helped us jump start our projects. Not only is she an administrative head of the hospital but she is a wonderful adviser for finding appropriate homes for our technologies.

Smartdrip: This is a device that I have been working on over the past school year. It monitors the drip rate and volume dispensed from an IV infusion for children. In many developing countries, IV bags for pediatric use are rare so hospitals have to use adult sized IV sets. However, because of the low nurse-to-patient ratio, lack of proper oversight causes unsafe administration of IV fluids, often over-infusion that can lead to death. Working in the pediatric ward last week, I have seen nurses use the adult-seized 5% dextrose, the most commonly administered IV fluid. To make sure kids receive within a safe range of volume, we helped squeezed the IV bags to the right volume, ejecting the extra fluids down the sink. I are excited to receive formal permission to demonstrate the device and possibly test it on a mock set-up in a real pediatric setting; however, the dextrose IV connection is actually different from a standard, so interfacing it with the Smartdrip design may pose a problem.

Dosing Syringe Kit: This kit consists of a 5c.c. and a 3 c.c. syringe with a set of clips for each that would be inserted in the syringe and thus, prevents more than a certain volume of fluid from being drawn. Nurses then can quickly, with accuracy and precision, draw the same volume of liquid—whether liquid medication or vaccine—each time. Matron Kamera advised us to demonstrate the kit in the pediatric ward as liquid medication is mainly administered there. Female and male wards use tablets while the ART clinic has decided to stop administering liquid HIV medication after conducting a pilot study with the Bill and Malinda Gates Foundation. It was found that mothers are less cautious with liquid medication. Moreover, once the liquid is spilt, mothers are unwilling to admit to their mistake and thus skip the return appointment. In the pediatric ward, benzylpenicillin and quinine are the two most commonly given liquid medication that are administered according to body weight. Unfortunately, the standard c.c. for the two drugs are smaller than 1 c.c. ( in the tenths range) while the kit has mostly measurements larger than 1 c.c. Moreover, the needle part used in the ward is too small to fit onto the nose of the syringe, which made us impossible to demonstrate.

Veinlites Transilluminators: These devices were donated from a Sugar Land biotech company. They may prove extremely useful because veins are not only hard to seen for dark-skinned patients but kids have especially small, seemingly-invisible veins. It is a common site to see nurses, like an acupuncturist, poking a needle on both arms, wrists and jugular area of a baby to try to draw blood or start a cannula. It is painful to feel the nurse’s frustration and the constant wailing from the babies.

Deering Scale: This small portable scale, originally used for weighing diamonds, has been tested by a senior design team to be accurate for pill counting. However, the hospital has access to digital scales that not only are more accurate to a higher number of significant digits but also are less sensitive to weight differences amongst pills. One big problem that we found testing the device at the pharmacy is that the range of the scale from 1 to 10 g is not universally applicable for all types of pills that need to be dispensed. Many pills, like Erthomyothin or Brufen , are not only very big but also given in a packages of 40 or 40, which weigh around hundreds of grams. The scale works for very small pills such as Diclofenac but when we performed an accuracy test, the packages using the scale are usually +1 in count, which proves its preciseness not its accuracy.

We did not have the opportunity to meet with Matron Kamera this week. In fact many friends whom I was excited to see again were gone. Alex, the nurse in charge of the community health worker outreach program, is at Blantyre attending a two-week study on palliative care. Sister Honesta, a nun in charge of the OPD pharmacy is also at a week-long training session. For a hospital constrained by resources in every way, St.Gabriel’s tries to fully utilize and mobilize its labor force. Because nurses are overloaded (for the Pediatrics Ward, I saw only one nurse managing more than 60 beds at a time), the janitors are trained to perform basic tasks, as counselors and administrators for HIV testing, as nurse-assistors, etc. It is notunusual to see janitors removing cannulas, taking vital signs or giving medicine. In fact, the hospital sends many to central government hospitals to become specially trained in an area. For example, a pair of lady cleaners, trained in the kangaroo method, are in charge of the neonatal ward where the hot cot and the phototherapy lights are situated.

We felt it was inappropriate for us to introduce the technologies we brought to the different wards without first talking to the Matron and receiving her permission. However, we used the time to check up on the technologies we left with the hospital last summer. Mentioned above, the phototherapy lights and the hot cot are in the neonatal ward where two specialized trained assistants are in charge. We learned from them that the hot cot is used for babies with extreme hypothermia. Otherwise, in most cases, the kangaroo method—where the mother straps the baby skin-to-skin in front of her chest—is one they recommend because they want mothers to bond with their children. Moreover, the kangaroo method is a easily sustainable way for mothers to maintain care for the babies after discharge. One other reason they are reluctant to use the hot cot may be that there is only one for the ward. Having one baby in the cot while there are multiple patients may cause discord. However, I was glad, and pleasantly surprised, that they do record the times they use the cot on the sheets that we provided them last time. Even though both ladies were not the audience I showed the cot to last summer, they eagerly demonstrated to Elizabeth and I how they used the cot and referred to the directions Z and I left them. There were, however, two areas of confusion. One was the placement of the board that the baby rests on. I guess when they wanted to check if the bulbs were all lit, the board was moved to the opposite edge opposed to the light bulbs; however, the correct placement is directly on top of the bulbs, which is designed so that the hot air can sweep across the baby before exiting the cot. Another problem was related to a part of directions that was not labeled clearly.  They were confusing the temperature the cot should be based on the baby weight and age (gotten from the Academy of Pediatrics) with the temperature the baby is at. As a result, they always used four light bulbs; however, they assured us that they always check the temperature within the cot when in use. Overall, I am glad to see that the transfer of knowledge from the doctors and head nurses I introduced the device to has successfully passed on to the ladies in charge of the ward.

The jaundice phototherapy lights (fondly called bili-lights) are also kept in great condition. The two units I left with the hospital are both working well. The two nurse-assistants know how to use the device with the cot and what the irradiance meter is used for. The device has not been used frequently because the doctors do not diagnose cases of jaundice often. However, the two units are currently the only working therapy lights as the donated unit from the US is broken.

We also checked on the oxygen sensor used to measure the oxygen level delivered by oxygen concentrators, which ensures that the machines are working properly. The main component of the sensor is the only replaceable part of the device aside from the batteries. The sensors are expensive and impossible to find in Malawi, so we brought a few to keep them in stock for the hospitals. We were just in time for the hospital’s monthly check-up of the oxygen concentrators and had a wonderful opportunity to observe how the technicians use the device. Everything was working fine and the sensor did not seem to need replacement as it was measuring the oxygen of the ambient air within the expected range. We taught the technicians how to replace the sensor if they ever notice the device measuring the ambient air oxygen level to be below 18.

Before arriving at the hospital, one of my greatest fears was that the technologies would not be used. I have learned before that it is emotionally hard to have high expectations in unpredictable situations, so I tried not to hope too much before coming. I am extremely thankful to St.Gabriel’s Hospital for their trust in our projects and their courage and enthusiasm to include new technologies in their healthcare system.