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A common tool for infinite variability

A colleague sent me an email asking for input to be used for an essay she was writing. It involves the development of content for community health workers in low-income countries.

First, some context. Community health workers (CHWs) are usually volunteers or very-low paid people--often women--who work in the health field. They are not clinicians and often have very little training. But they can be effective in working rural areas and villages in many places around the world. In India they are sometimes called ASHAs--Accredited Social Health Activists. In that setting they work for the state ministries of health and register women in the healthcare system who are pregnant. The idea is to help the expectant mother to maintain her health during her pregnancy and afterwards by also helping her new baby stay healthy. ASHAs can provide information the progress of the pregnancy, on nutrition, and the like. They can even call in a clinical referral if the mother seems to be having a health issue. They can also show the mother and her family information to help them understand and support her during the pregnancy. So, you can see where there is a chronic and serious shortage of doctors and nurses, a community health worker may help the work of those clinicians be more efficient by working with the population being served.

My colleague works in this context and tries to develop programs to support CHWs in a variety of countries. She posed the question of how we might best develop training content for these workers. It's expensive to develop, so if we can do it once and disseminate it in many places, that is an efficient approach. The problem is that there are important differences between many of these places. Differences exist in language, culture, literacy levels, availability of communications technology, transportation systems, healthcare services, and on and on. The best solution is to develop these materials locally. But that can be very expensive because every one of them is unique.

I once worked on a series of projects to address this type of issue--creating a common platform for a variable purpose. It was a long time ago with what we would consider much more modest technology, but the issues are the same. How can we provide individual information that is relevant to that person at scale. By scale, we wanted hundreds, even thousands, of variations on the messages to be delivered. They might range from smoking cessation to healthy diet to exercise tips. The messenger could be a physician, a nurse, or even a member of the clergy. The messages could come as a calendar, a newsletter, a greeting card, or even a letter from a pastor. We were trying to find out what approaches worked, but to do that we needed to have some sort of engine to generate all these documents (by type, by topic) that were addressing the issues every individual had. Those issues included literacy level, gender, education attained, health status, etc. At one point, we calculated that with the variety of messages we could develop plus all the above factors that we could have 1.4 million variations. How could we code that?

The previous approaches involved standard branching logic. It would look something like this:

  • If the person is female, then
    • If she is under 19 years of age, then
      • If she is a smoker, then
        • If she smokes every day, then
          • If she has thought of quitting, then
            • Present her with a message to identify a quit date

You can see that for every set of variables, these types of nested branches could be very long and complicated. I was amazed that the previous team had made that work at all. They had tens of thousands of such lines of code. The challenge facing me was that I had three new projects that required that type of logical branching across several topic areas and on a variety of media (the aforementioned calendars and so forth).

How could I approach the task? Well, skipping to the solution and bypassing lots of effort, I realized that if I created a container that was a simple table, I could address all the variations involved. So, I defined each object in a document (a place for a picture or a sentence) as a row in the table. In each row I created up to 10 columns for the characteristics of the person that related to that object. For example, a pregnant woman who was a smoker and wanted to quit, but had not set a day to quit might get a message about doing just that. Or perhaps a picture of a calendar with a date circled in red to indicate a quit date. The idea was to match her profile to the row containing characteristics she possessed and choose the object (in an extra column) that contained the relevant text or picture.

While it took a lot of effort to develop all the messages and pictures needed, the process of choosing them and constructing an appropriate document was much easier than embedding the logic in the code. I just wrote routines that would look at each area of a document and the relevant types of data to choose what to put in it. That was a search string that looked for the appropriate match in another table, the one I described above. A hit would allow the code to select that object and put it in the document. (Okay, it took months to work all the above out, but it did work.)

My point is that we can now take such approaches to address the issues of context and uniqueness from where I began this essay. While language and cultural expectations may vary from place to place, if we are considering issues such as a human pregnancy, there is a biological norm that we can use as a reference. That offers us a way to build a table with potential issues involved in a woman's pregnancy with material relevant to those issues. We can add versions to address linguistic variability, cultural norms, health system personnel and practices, and so forth. We could construct a matrix that allows us to store standard messages and materials that can be selected for local use by setting some parameters. It would involve lots of thinking in advance, but the system could be made able to evolve as more people participated in it and more topics were addressed.

In a way, it's the shape of the container (the rows) and its characteristics (the columns) that might help us address the issues of variability in a common way. It might be the way to create a common container that holds all the needed variations in a format we can search.


I'm Back, Still

Dear Readers,

Both of you. While I have not posted on this blog for many weeks, I've been continuing to write my thoughts and observations down from time to time. I'm going to post those with dates of release of when I originally composed those essays.

So, read on.

The Future of America

I have seen the future of America—in the developing world. The difference is that they are building a middle class, and we are deconstructing the middle class. But there’s more involved. Read on. 

If you have ever traveled in Sub-Saharan Africa or India, you have probably encountered potholes of legendary size, roads that are more a suggestion than reality, bridges that are alarming because they move when not designed to do so, and airports that resemble the worst of American bus stations with a couple of LED screens sprinkled in. You’ve seen whole villages of people living under bridges—infants, children, parents, and grandparents all together. You’ve seen guns—everywhere—especially large-calibre automatic weapons with lots of ammunition. Every “nice” hotel sports an armed guard, or even a armed squad, at the entrance. Every “nice” house is surrounded by walls topped by very sharp wire or steel spikes. 
Paradox: Hotel keys in Namibia
21st Century meets the 18th

But the situation on the ground is changing in the developing world. New airports spring up that are gleaming and hyperbolically clean. African governments are bootstrapping investments in universal health care and educational opportunities. New roads appear where trails of mud existed before. They are aided by a variety of international institutions ranging from the UN and World Bank to the Gates and Rockefeller foundations, even national governments like our own and the UK. They are building new infrastructure partly because not much was there before these efforts. 

In the United States, we are transferring resources from the many to the few at an alarming rate. Our rates of income inequality are only overmatched by disparities in wealth. The disparities have reached levels that pertained just before the Great Depression and rival those of the Gilded Age. Thomas Piketty has offered a fact-filled and compelling portrait of wealth and income aggregation at the top of the pyramid as evidence that these are historical trends that will be prevalent without active intervention. At the time this fascinating work came out, the US continues to keep chipping away at progressive income taxes through an over-complex tax code and a very low estate tax that confer disproportionate advantage upon the advantaged. 

Compounding these efforts is the persistent defunding of public education from kindergarten through graduate school. The rise of private academies not only takes funding away from public schools, but offers subsidies to families directly through tuition vouchers and indirectly through charter schools. College tuition continues to rise faster than both general inflation but more worrying general income growth. This is because investment per student has not kept pace with inflation which was compounded by the recent recession that reduced funding significantly. Public universities responded in part by compensating for lost public revenue by raising tuition—like American automobile companies confronting declining sales in the early 1970s by raising prices. It did not help those companies then and rising college tuition will have even more damaging impacts as more qualified students are denied access to higher education every year. 

The tent in the middle is a restaurant in Dakar, Sénégal 

As big as these disparities are in America, there’s still a lot of potential for their growth. In Sub-Saharan Africa and India I have seen greater disparities between rich and poor. Moreover, the rich overtly protect their material conditions and security with walls, barbed wire, and armed guards. We have protections for the rich in America, but usually they are more polite. True, there are gated communities and the American mobile protective envelope--the standard issue SUV--but armed force is not often used. (There have been historical exceptions, however.) The US armies of the rich wear very nice designer clothes and offer campaign donations to those they seek to protect their masters through loopholes and favorable legislation. 

So, if you want to see what the future of America looks like you don’t have to travel far. Stop, carefully, and look closely at a bridge or overpass to see the cracks and rusted metal needing repair. Visit a school board meeting and ask how many students are there per teacher over the past ten years. Even better, how may students per teacher’s aide. Count the number of un-repaired potholes on your way to work, then increase that number to see what things will look like in a few years. 

Finally, conduct a financial thought experiment. Take the current national minimum wage, $7.25, and multiply it by 160. That yields $1,160 for a month of work. Consider what you spend on your mortgage or rent with that number in mind. Consider what you spend in a month on food, both groceries and dining out. Consider your other bills—utilities, car payments, fuel, maintenance, clothing—the other necessities. What’s left? Chances are not much, if anything.  

Welcome to the future. 


The Academy and Action

I’m sitting as I write this in an academic meeting and trying to pay continuous partial attention to the speaker. As he relates his findings, I’m struck by the notion that these proceedings are now global in nature. I can say that because I’m sitting in a conference center in Maputo, Mozambique, with a couple of hundred participants from across Africa, Europe, Asia, and North America. The center offers simultaneous translation services between Portuguese, English, and French. Each seat sports a headset where you make your language choice. But the point of this essay is not just the global nature of the setting, but the universality of academic meetings. 

Simultaneous Translation Device
How to hear English--press the button
I’ve been attending these sessions off and on for over thirty years: Meetings that include the humanities (I’m really just a recovering historian) as well as scientific disciplines that include medicine and public health. They almost always feature a speaker or panel of speakers with others in the audience listening and sometimes asking questions at the end of a presentation. Almost everyone uses slides to complement their speaking part, sometimes just reading the slides. People in the audience used to daydream or doodle on paper if bored, but the advent of portable communications devices changed that. Now, people answer email, surf, revise documents, and even write blogs. But even that is not the point of this essay. 

I’m struck that in the United States, the scientific community seems to have become less relevant in the discussion and development of government policy. Granted, the scientific method of hypothesis and investigation often is not well understood by the general public—despite the efforts of countless middle school science teachers. The literature is routinely written in the passive voice because the intention is to let the evidence speak rather than the scientist. Public figures experienced in the combat of debate and campaigns may find such findings often tentative and difficult to follow if you are not a specialist. But that’s not the point of this essay. 

One of the hallmarks of the countless such sessions I’ve attended is the politeness of the proceedings. I can count on one hand the number of times there was controversy and verbal conflict in any of these sessions. They tend to be technical and filled with lots of data and evidence, but not much in the way of implications of these findings. Scientists often do not know how to communicate either beyond their technical specialty and certainly do not like the parry and thrust of the political arena. (Perhaps bringing classical debate to the scientific proceedings might liven things up.) I worry that the community has lost its voice in the public arena because of this civility. And that’s the point of this essay. 

We sometimes are governed by people with an active dislike for science and all the procedures and culture involved. I base that on the variety of evidence available online and C-SPAN recordings of our political leaders discounting scientific evidence in making policy. I also cite an instance when I attended a public meeting about basing a biomedical research facility in my home state. One of the speakers from the general public stood up to complain that she did not know what kinds of dangerous research might take place there. She literally spat out the word, “scientists”, to focus her rage, dislike, and distaste. How can we respond?