Research to Practice: Booth Professor, Alumna Team up to Fight Malaria
Rustandy Center research partnership aims to develop supply chain, deliver health supplies in Democratic Republic of Congo.
- April 08, 2021
- Rustandy Center for Social Sector Innovation
Dr. Amy Lehman thinks a lot about mosquito bed nets and other health interventions, designed to stave off malaria infection in a part of the world that sees the highest death rates related to the disease.
She’s dedicated her career to figuring out how to get life-saving medical supplies to villages in the South Kivu Province in the Democratic Republic of the Congo—a region in east-central Africa that’s often considered too costly to reach. It borders on Lake Tanganyika, the world’s longest freshwater lake that contains one-fifth of the globe’s freshwater and touches four nations with a total population of over 170 million.
In 10 years, she’s learned two basic truths: insecticide-treated bed nets are not the best way to fight malaria in water-based communities, and the key to reliably, safely, and affordably delivering another health solution lies in developing a supply chain in an area whose main highway often becomes the lake itself.
“We know that bed nets are not the best solution,” said Lehman, AB '96, MBA '05, MD '05, a graduate of the University of Chicago Booth School of Business, the Pritzker School of Medicine, and the College and founder of the Lake Tanganyika Floating Health Clinic (LTFHC). “People were using their bed nets to fish around Lake Tanganyika. Mosquitos are biting people before bedtime, and the bed nets are hard to use if you don’t have a bed or a bedroom.”
What Dr. Lehman needs is more data to show that another solution—like a spatial repellent—works better, and an operation model that accounts for cost, local conditions, consumer demand, product lifespan, delivery frequency, seasonality, and sustainability.
Her group is working to test new approaches to overcome last-mile delivery issues—something they’ve dealt with for years, long before the COVID-19 pandemic exposed cracks in the world’s traditional supply chains. To drive that work, Chicago Booth’s Rustandy Center for Social Sector Innovation connected her to Baris Ata, Booth’s Chookaszian Family Professor of Operations Management and an expert in resource allocation, sustainable operations, and improving efficiency.
The two of them recently spoke at a Rustandy Center event to share insights from their efforts to build a sustainable supply chain that would allow them to deliver anti-malaria technology by boat, motorbike, canoe, and more on a monthly basis.
“If We Can Make It Work Here, It Could Work Anywhere"
Between 2000 and 2015, the United Nations reported that malaria cases fell by 37 percent globally and death rates by 60 percent. Progress has been uneven, however. Children under five are the most vulnerable group, accounting for 67 percent of global malaria deaths. Over 90 percent of worldwide malaria deaths are still concentrated in a small group of African countries, with Nigeria and the DRC leading the pack.
Baseline data from Dr. Lehman's clinic, including surveys of households, shows that 30 percent of 2,090 fishing parties observed were using insecticide-treated bed nets, which, in turn, poses harm to fisheries, food security, livelihoods, biodiversity, and health.
Professor Ata’s study, conducted together with Booth PhD student John Montgomery, seeks to test both the efficacy of a new and innovative malaria prevention product that may be better suited for water-based communities and a supply chain delivery model for last-mile communities.
To build a sustainable supply route, they considered potential disruptors: In the DRC, the main highway is a dirt road. Seasonal weather events regularly wash out roads or make the lake inaccessible. The area also experiences political unrest and conflict, so researchers mapped distribution sites and built contingency plans for potential disruptions into their model.
“These are the operating environments that we have to learn how to deal with because that’s where people are dying,” Dr. Lehman said. “That’s where people have the greatest need. Our job is to fundamentally understand how to operate within those types of complex ecosystems.”
Professor Ata and Montgomery developed mathematical models to evaluate potential solutions. Their model weighs every solution against lives saved per dollar spent, which factors in the cost effectiveness of delivering health products to households on a regular basis.
For malaria prevention, they’ve narrowed focus to a spatial insect-repellant called “The SHIELD,” a SC Johnson innovation that’s the size of a sheet of paper and hung on the wall of a home. The average home would require four sheets and they need to be changed out monthly.
For the supply chain, researchers recommend building storage units for boats near the lake to reduce reliance on roadways, establishing modes of transportation to overcome each type of disruption, and determining a resupply policy that accounts for demand as well as potential disruptions.
“If we can make it work here, it could work anywhere,” Professor Ata said. “Of course, this is not a one-size-fits all model, but the same principles could be applied to different contexts.” He compared planning supply distribution in the region to playing chess, needing to think 10 steps ahead.
“The Rustandy Center prioritizes research with practical implications,” said Salma Nassar, the center’s director of research initiatives. “We work to develop research partnerships between leading academics and partners in the nonprofit, for-profit, and public sectors. The collaboration between Amy, Baris, and John is poised to provide important insights for building reliable supply chains for health interventions.”
Lessons Learned and the Road Ahead
To test their ideas, the group needs funding to launch a pilot program. Dr. Lehman is seeking local buy-in from authorities and the community.
It’s easier to stick with bed nets as the solution, she said, because they’re inexpensive, can be distributed every few years, are familiar to donors, and can be effective outside water-based communities. But the group hopes data from a pilot could cause a serious shift in approach and policy.
Professor Ata thinks this research and learnings around decentralizing operations could be valuable to others navigating supply chain issues and wanting to scale up. Take the COVID-19 vaccine, for example, he said.
“Creating a vaccine is important, but how do you distribute it to everybody? A lot of times we go with extreme efficiency instead of allowing for flexibility.”
He hopes their models can be adapted to other situations, and plans to release a working paper on the research, alongside Montgomery, later this spring.
Dr. Lehman wants research to prove to the international development community that there are cost-effective ways to serve communities disproportionately affected by a health problem.
“You can only pick so much low-hanging fruit before all the fruit is hard to pick. We’re at that point with malaria control,” she said. “Now what we’re left with are literally the hardest places to serve that have the highest mortality figures. My hope is that we can actually begin to show ‘this is how much it costs’ to serve these people who have this unacceptable mortality rate.”
Watch a video of the research discussion below, and explore ways to support the Lake Tanganyika Floating Health Clinic. If you're interested in this work, sign up for the Rustandy Center's monthly newsletter to receive articles from Booth faculty with ideas for accelerating impact in the social sector and updates on relevant news and events.
Well, thank you so much, thank you so much for being here. I'm Randy Kroszner, I'm the Deputy Dean for Executive Programs and a professor of economics at the Booth School of Business at the University of Chicago. And as you can see here in this beautiful London campus, I've been in London for the past 18 months and it's been quite a challenging time, but we have a beautiful campus that we've been in London for 15 years, and we kind of commemorate that by moving to a beautiful new campus almost a year ago. I haven't been able to welcome as many people as I would like to the campus, because the health challenges, but we're gonna be hearing a lot about innovations in dealing with some of the health challenges here today. So I'm very excited about that, and hopefully that will pave the way for me to be able to welcome all of you to visit the beautiful London campus, so close to at the St. Paul's sometime soon.
Today's event is hosted by Chicago Booth Rustandy Center for Social Sector Innovation. And it's really the social impact hub for everything we do at University of Chicago Booth School of Business. It's really the crucial center point of the social impact ecosystem that we have, and it promotes innovation and advances in research and supports people in taking a lot of the research ideas and putting them into practice. And that's exactly what we're gonna be talking about today. Is you're gonna be hearing about some very important research on the South Kivu Province in the Democratic Republic of Congo.
But to give a little background on that, it really starts with, with Dr. Amy Lehman, a graduate of Booth, of the College of the Pritzker Medical School, at University of Chicago, and she was the founder of a non-profit called the Lake Tanganyika Floating Health Clinic, and in East Central Africa. And it's an enormous fresh water lake, river and tributaries, and it touches on multiple nations, four nations with 100 million people associated with it. And with really no infrastructure and limited supplies, what Dr. Lehman has been able to do, is build water routes to deliver medical supplies too hard to reach areas in this region.
And this is really where Rustandy and research comes in. 'Cause the center connected Dr. Lehman to my colleague, Baris Ata, who you'll be hearing from, and who's an expert on operations management and logistics, and his work on resource allocation, sustainable operations and improving efficiency, was very helpful to work with Dr. Leman and her group, to test new approaches to address the last mile delivery issues. Which of course as we know, whether it's jabs in the arms for Corona virus vaccines, or just the delivery of medications, that's often where the bottleneck is, of actually getting it, not just to the country but to the individuals who need it. And trying to deliver these critical malaria supplies by boat, motorbike and other means.
So it's really been a fantastic partnership to bring ideas, research together with practice and particularly with our graduates, to ask the big questions and find solutions for them, practical solutions for them. And so now what I'd like to do is introduce Rustandy Center's head of research initiatives, Salma Nassar, and my understanding is that Salma was the key person who introduced Dr. Lehman and Professor Baris Ata. So without further ado, welcome Salma.
Thank you so much, Randy, welcome everyone. I'm Salma Nassar, I'm the director of research initiatives at the Rustandy Center. I lead this center's research arm where we support groundbreaking research on the social sector and on complex social and environmental issues. At the Rustandy Center, we work with faculty and PhD students to develop social impact research across disciplines at Booth. For instance, we have built and manage a data hub, which includes over 10 unique datasets that can facilitate research on multiple topics including non-profit governance and corporate social responsibility. We also develop research partnerships between leading academics and non-profits, for profits and public sector organizations, and as Randy's shared, you'll be hearing more about one of those partnerships today, between Dr. Amy Lehman and Professor Baris Ata, as well as PhD candidate, John Montgomery.
So a couple of recent examples of our research work, when COVID-19 hit in March, 2020, we launched several COVID-19 research projects including the partnership with UChicago's Inclusive Economy Lab and Homebase, which is a scheduling software for small businesses, and we were able to track in real time the impact of the pandemic on small businesses and small business employees in the US. We also recently launched the Impact Finance Research Consortium, in partnership with the Harvard Business School and Wharton to build a database for academic research on impact investing.
But I know everyone's eager to hear from our speakers, and so I'll just share a bit more about them today. Professor Baris Ata is the Chookaszian Family Professor of Operations Management at Booth. In addition to his work on last-mile delivery, Professor Ata's research interests include operational issues in the criminal justice system and delivery of healthcare services. He takes a problem-driven approach to bridge the theory and practice of operations management, having used stochastic models to study delivery of healthcare services, sustainable operations, management of manufacturing and service operations and revenue management. He has received a number of awards for his work including the William Pierskalla, Best Paper Award in 2015, as well as the Manufacturing and Service Operations Management Young Scholar Prize in 2015. Professor Ata also serves as editor of the Stochastic Models and Simulations Department of Management Science.
Dr. Amy Lehman is the founder of the Lake Tanganyika Floating Health Clinic and Iroko Health. She's an expert, advisor and partner to actors as diverse as regional governments and local tribes and to donor organizations, philanthropists, non-profit organizations, and multinational corporations in the Democratic Republic of Congo and the African Great Lakes more broadly. She received both an MD and MBA from UChicago, and trained in general surgery at the UChicago Medical Center. Dr. Lehman also has received several awards including the 2014 Distinguished Young Alumni Award from Chicago Booth. She was named the 2014 Chicagoan's of The Year, and was honored by Newsweek as one of 150 women who shake the world.
Today's conversation will be moderated by Caroline Grossman, Executive Director of the Rustandy Center, and an adjunct assistant professor of strategy at Booth. And with that, I'll hand things over to Caroline.
Hi, everyone, thank you so much for joining today. The introductions have been terrific, I'm gonna launch it in just a moment but I have two things to tell the audiences here today. We opted to do this as a Zoom meeting, so that you can see each other, we can see you, you're welcome to keep your cameras off, you're eating lunch, whatever else, you're also welcome to turn your camera on, and there will be plenty of time for questions. You'll be able to raise your hand and I can call on you with a question. You can also put a question in the chat and I will try to weave in questions throughout. So please don't hesitate.
So turning to our speakers, and Amy and Baris, if I may shift to first names for this conversation, Amy, could you give us a short history of the Lake Tanganyika Floating Health Clinic, in particular, why malaria, and what is the need for new malaria prevention technologies?
So I love talking about this. Maybe it's the UChicago geek in me that I'm just obsessed with this particular topic, but I don't wanna spend too much time talking about sort of the founding of my organization. I'm happy to answer any emails that anybody wants to send me offline after this event is over, that's totally fine. My email is email@example.com. If you have anything pressing you wanna ask me, but I wanted to dive in immediately into this kind of thorny problem about malaria control, to give a little bit of background.
You know, the UN developed a set of Millennium Development Goals, and the kind of golden child of the Millennium Development Goals that were sort of held up as a success story, was the Millennium development goal of decreasing malaria incidents by a certain factor. So 54 countries managed to achieve their Millennium Development Goal of reducing malaria mortality by 75%, okay?
Except that when you look at the deeper statistics on that of those 54 countries, those countries only represented about 5% of worldwide malaria deaths. Malaria death and malaria incidents, and this sort of social impact of malaria, is extremely heterogeneous. And it's really a small group of African countries that account for almost the majority of all worldwide malaria death and of that small group of African countries, two countries really stand out as being the main contributors to malaria death. And when I say malaria death, I really mean the death of children under the age of five, because that is the largest group of people who are affected by the disease, followed by pregnant women.
So DRC is one of those two countries, the other one is Nigeria. And so I'm working in a country that is one of the, you know, main drivers of worldwide malaria death. We're kind of 10 years and beyond into universal bed-net strategies as the way to control malaria. And we noticed a lot of things in the field, post universal bed-net distribution. One is that there was still a lot of malaria and it was still killing a lot of people. And then number two, we also noticed that people were using their bed nets to fish in Lake Tanganyika. And we noticed it in all four countries around the lake. So we were trying to understand, okay, what's the mechanism what's going on here? And that actually resulted in my first collaboration with a Booth faculty member, that was with Emir Kamenica who is a behavioral economist and working with some other collaborators, we designed very involved household level survey, where we looked at multiple indicators in a certain catchment area to try and understand what was happening with high malaria rates and kind of bed net failure. And we discovered some really important things.
One is that the bed net doesn't really work if you don't have a bed and you don't have a bedroom. That's one really big problem. Number two, mosquitoes are creatures that respond to environmental pressures. That's how natural selection works. And so over the period of time, when mosquitoes were coming into contact with these bed nets they slowly changed their biting times. And so they were biting people before bedtime. So even if you slept under your bed net, there was a really good chance that you would get bitten by mosquitoes before you went to bed.
Then we were also studying an area that had multiple stressors. You know people had a lot of problems, including food insecurity. And so if you're a mother who has to choose between trying to figure out how to feed your children today versus prevent a theoretic case of malaria in the future, your choice is clear. And so we were able to kind of tease out a lot of these issues. And one of the issues that we also understood is that people were expressing a fundamental product preference. They wanted a spatial repellent to keep mosquitoes out of their house. And so there are spatial repellents that are on the market and have been developed, but they have a completely different product life cycle. So that is where, (laughing) Baris and I got together to try and think about how to deliver the right product into these communities.
Amy, I'm very much looking forward to getting into that collaboration and partnership and work you and Baris have done together, but I think there's one more thing we need to do first which is just take a moment to think about the complexities in the North Kivu province, and how they interplay with the challenges for last-mile delivery in the region. We recently saw an example of one of these complexities when the Italian ambassador, Luca Attanasio, and his bodyguard, Vittorio Iacovacci were murdered during an attack on a World Food Program convoy, headed to North Kivu Province. So can you just provide a landscape or just an overview of the complexities in the region?
So, yes, so that kind of tragic event, is an example of how, you know, physical insecurity, you know, tremendous poverty, kind of regional political complexity, all kind of overlap and create, you know, circumstances that have a lot of variables in them. But the reality is that if you look across the globe, at where the most intense health problems are, and where the most intense security problems are, and where kind of intractable poverty is, and sort of, you know, physical insecurity. Unfortunately these are the operating environments that we have to learn how to deal with. Because that's where people are dying, that's where people have the greatest need, and the way that the international aid and development system is set up, is that you have these kind of siloed disaster responders, to an event, a war, and then you have the kind of institutional aid and development.
And really neither of those two buckets really describe the vast majority of these kinds of circumstances where humanitarian aid is required. It's a mix where you have these long simmering, you know, conflict, post-conflict environments that have a lot of different variables associated with them. And even though it's really really hard, our job is to fundamentally understand how to operate within those types of complex ecosystems.
So as Dean Kroszner and Salma described, since 2018 your foundation has been collaborating with Operations Management researchers at the University of Chicago Booth School of Business to develop and test robust supply chain models for household distribution of public health products in this region. So let's get into the specifics of how you collaborate on this. Amy really briefly, what data are you able to share with Baris? And then Baris, how do you use that data?
Well, so when got started with our collaboration, we actually handed over this massive dataset that we had collected in the previous year. And were able to kind of drill down and organize and clean up this data in a way that could lead us to start posing the kinds of questions and looking for certain kinds of answers, you know, from the kind of jumping off point of having this big baseline dataset. But then now I wanna hand it over to Baris to explain and how he took those data and started slicing and dicing. (laughing).
Right, right, right. Think you can you hear me okay?
You know I should start by thanking the Rustandy Center for making this collaboration possible, right? Through Salma and Caroline and so forth. We had connected with Amy and there are lots of great things happening there, but something is our mentality is really really, I think in line. We all know this type of work is important, right? So it's gonna have impact and all that. But I think the part that we were so aligned, was we wanna do it right, we wanna do it well, we wanna do it rigorously, and Amy has trained us about the area and all that. And we also have the baseline data. And I also wanted to put together a couple of slides to walk people over through maybe some pictures and so forth. And so, I also asked Allie, and Allie told me there are going to be former and current and students, I figured this is a great opportunity for a refresher on my course, right? So here is, you may remember the ABC's of optimization modeling.
So let me reiterate also that there's a PhD student, this is his thesis. And John and I approached this just like we would approach any business process optimization. There's like the same approach, same level of rigor. And here let's say, I wanna first focus on what's our objective in the space, right? So I come in with no preconceptions of what we should focus on, and we try to understand that, which is what are managers’ goals. The possible goals are things like, you know, some sort of quality adjusted life years or things of that sort, lives saved, right? So we wanna maximize something here, right? So we said, I think I'm in your way here, so let me do this. So we wanna maximize say life saved, maybe we said, you know, dollar spent matters too. Of course we wanna save lives, but at the end of the day we are working with limited resources. So we say, let's try to look at this, right? That seems to matter. That would be said, this is the first leg of the project, there's a second leg that I also say at the end, you say, given a certain area that we wanna share, how do we minimize the dollar spent for that? How do we do this in the most cost efficient way, right? So that was our focus so far.
And let me tell you a little bit about the area. So this is where we are let's put it on a map, right? So, and we wanna look at the problem of access, here's kind of map, obviously not as detailed as the map (indistinct) always curious around. But so here is a more detailed map of the area. So this is where we wanna operate, right? So, and I really want you to be thinking about this as a proof of concept, right? So it's not a small area but it's not a large area either, but we are thinking about 41 villages, over 200,000 people. But think of this as a very challenging test problem, proof of concept. If we can make it work here, that's gonna tell us a lot in terms of scaling it elsewhere.
So it just sort of the ideal research room. Let me tell you a little more about sort of the infrastructure, because at the end of the day, that's gonna matter. So here is the highway structure or really a single highway. That's like their major highway as they understand. Think of it like, if you're in California, Highway 101 type of thing, right? So let me show you what it looks like. Here's your major highway right here, okay? This is it. Now there are problems with it. So Amy talked about some of these issues, right? So with the business. I felt it's good to show you some pictures. Let me completely get out of your way here. So here I don't exactly know what this is but it doesn't look good. Here's a creative use, the bed net for a soccer goal. People are fishing here, they seem happy, that's good, but that's really not the intention of these bed nets, right? So this is probably the most creative one. This is a soccer ball they made out of bed net.
So these pictures and there are many pictures and videos of these misuse and so forth. But given the trade off that Amy mentioned about, you look at food insecurity versus malaria, and people may have to make impossible decisions there. So one solution that could work better is the spatial repellent. This is called the shield SC Johnson has this product, the idea is you put it on the wall, it's great. But there was a challenge because this is gonna last for say a month.
They say maybe up to two months? I'm not sure, but let's say a month or so. The point being this now becomes relatively perishable and you need to resupply on a regular basis, okay? So that's sort of what we need to focus on.
That brings me to the challenges that we would face that this is gonna introduce a whole bunch of constraints. Let's look at quickly here the limited infrastructure, right? So this highway here could be often quite congested as you see here on the left, right? Now, what is worse is that when there are extreme weather events, like mudslides and so forth, this is what you get, okay? And again, let me remind you, this is the highway, here is a very brief video. Now this is what became of the highway, okay? It's all part of the lake now, in a way, as I understand it. It was very creative way to save the car, I suppose, but you get the idea, right? Now the question is, how do you do the deliveries in this complex setting? Like we don't have a choice. When I talk to people about what they are doing during the pandemic, especially like healthcare workers working under very challenging situations, they tell me, well, I have only one choice, which was to do this and I'm doing it. Right now this is what we have, and we are gonna work with the tools that we have, right? And Amy referred earlier to a political unrest and things like that. So I'm gonna turn to Amy to tell us a bit more about this gentleman here and maybe the over overarching issues in this context.
So one of the kind of hangovers of the Congo Wars is that there are about 120 armed groups, that operate in the East of the country. So from sort of the Northeast down to kind of the mid Southeast, sort of North Kivu to the Northern part of Tanganyika Province. And this gentleman here is William Amuri Yakutumba, who represents the most significant rebel group in the area of interest for us. And so there are villages, for example, that Yakutumba controls sometimes that control can shift between the army, the National Army and this armed group. But needless to say, that adds another layer of complexity, when you wanna move goods up and down, you know, that area of control.
Right, for us at the end of the day, you know, I work with mathematical models, John works with mathematical models. These are just disruptions to us, but different kinds of disruptions, how do we deal with it mathematically, right? We say, okay, we're back to my class. And just what are our decision variables, okay? What is at our disposal? What did we get to decide, right? So first one is established possible modes of transportation under each type of disruption. First of all, do you have the roads available to you? If not, maybe you're gonna come up with like this motorbike, this type of creative solution. Here's a boat, right? You see Amy here, I think, hi Amy in the picture, okay. So the other thing that we want to do and John has been working on this, like thinking about how to get there and assemble these, I think he wants to do some of it himself, is storage. Reliant storage places at the end points and the villages so that we can sort of rely when we store them. The motivation again is that determine an optimal resupply policy that's gonna account for frequent and random disruptions. We are not gonna know when, we know something is gonna go wrong.
But the question is, we don't know when and what, but we know something is gonna go wrong, right? So that's more of the norm as I understand things. So let me tell you briefly what we've done so far, or rather what John has done so far. Is he found a way to minimize dollar spend, to do this most efficiently. And the next step is to kind of test this solution through a pilot program, right? And I think I'm gonna get in your way here. So what then we'll do is try to measure this quantity here lives saved per dollar spent. Now, if you took my class, this should sound like shadow price, right? So it's a very useful concept if you didn't maybe you should think about it. It's a good class.
So our next focus is going to be the figuring out what is the impact on the life saved, right? So here some pictures. I'm gonna show you a small part of John's analysis. He considered a whole bunch of cases, it's quite a bit of math, more math, John loves math, that's sort of one take away from this, but the point is this. What I wanna highlight here is that it is not the case that we have the tools existing. And we just took it off the shelf and said, Amy, this is how we do it. No, because this setting is so unique, it hasn't been studied before. There were things obviously we could build on in our literature, but John had to innovate, and move to state of the art, right? And if you wanna see more of his map, obviously we'll be happy to share his thesis, but I'm gonna spare you further details.
Let me finish with this. Why this city, from our perspective? Well, first of all, I mean go where the need is greatest, right? So this is kind of, as far as I can tell, is the most challenging setting you can think of, if you wanna do supply chain last-mile delivery. I can't think of a more challenging setting. If you do, let me know, I'm gonna start working on that too, right? Because the whole point here is, yeah, this is maybe a small area. I mean, it's only 300,000 people but it really is a proof of concept, right? So if you can do it here, that lives per dollar saved will get a very good benchmark for further solutions, and it's gonna motivate us. I think looking beyond sort of one size fits all solution, we have to start thinking more broadly and say, hey, for this type of area, maybe we need this type of solution, for this other area of business it may work great and so forth. So in that sense I think this study is really exciting. With that, I'm gonna turn back to Amy.
So Amy, actually, so what I'm wondering is what's next? What's next in your plans for collaboration and really putting this research and modeling into action at the Lake Tanganyika Floating Health Clinic?
So what we've been working on, is kind of pulling together the funding so that we can actually run this experiment. I actually was just in Kinshasa a little while ago, talking with the authorities about doing this operational research in the area. I had a meeting with the head of the National Malaria Control Program, who's very excited about this. 'Cause the reality is that, you know, malaria control in many parts of Congo is really interactively difficult with the current tools that are on offer right now. However, it is gonna require some very serious shifts in operational approach, in order to start deploying different kinds of tools.
And so to put that in perspective with kind of a bed net only strategy, what the international aid and development community has kind of honed over the years is doing like mass bed net distributions, every, you know, three to four years, okay? Mass bed net distributions every three to four years are nothing like a cycle of consumable health products that need to be renewed on a much more regular basis.
However, we think they're also some really exciting, you know, additive effects. and that is that some of these places have like 85% unemployment. And so if you can figure out ways as well to involve the community itself in some of these legs of delivery, you know, that is really very additive, because in that part of the world, you know, extreme poverty is as much a driver of poor health outcomes, you know, as the malaria parasite is. So thinking, you know, more holistically and kind of accepting the complexity, and the challenges that the complexity imposes on us, is kind of what we're gearing up to do, we're figuring out.
Okay, how can we do the setup? How can we get these structures? These, you know, local inventory sites set up, how can we work with the local populations and sensitize them about the new product, working with all of the local political authorities, you know, managing Yakutumba, (laughing) that's what we're working on right now. (laughing)
So my understanding is that there's hope that this research can show that there are strategic ways to conduct last-mile delivery that can be cost efficient and provide stable, reliable service. And over the past 10 years, we've seen events such as natural disasters, COVID-19 and so on, that have caused significant supply chain destructions to regions that don't usually experience instability. Are there lessons that we might be able to apply, Baris, from this research during these types of emergencies?
I would think so. I think there are several aspects of the problem that relate to it, right? So one is this notion of decentralizing mentoring management, that sort of how the couples, and when there is something going wrong that gives you some sort of a cover, right? And this whole logistics challenges and disruptions, right? So how do you build a flexible, robust supply chain design?
So a couple of weeks back, we had a kind of a hiccup in the vaccine distribution, because of the storms and this and that. So we now see, oh, okay, there's this matter, and of course, a lot of us knew that, for one thing, I mean, I don't wanna minimize the try, so coming up with a vaccine that's so impressive, it appears to be so impressive, it's just amazing. I'm just sort of so grateful to those researchers really. But again, I knew that was just part of the challenge, the second part is how do you distribute to everybody? No matter where they are, right now we are worrying about the developed countries, but at some point the whole world needs to be vaccinated for that to work really, right? So reaching everyone and how do you do the last-mile delivery?
Now for us we are lucky in the sense that pandemics happened at least so far, rarely, and I hope it stays that way, but in that part of the world, this is rather the norm, right? So unfortunately. But in that sense I think there's a lot that we can learn. And so how do you, a lot of the times we go for extreme efficiency, and not think so much about the flexibility and in some ways I think we undervalue flexibility and robustness. Sometimes maybe it's okay to be a little more expensive, but be more robust in terms of the system failures, right? But I would also step back and reflect back on something Amy said earlier. I suspect that the damage caused by malaria in these communities, I may be wrong, correct me, Amy, if I'm wrong, but it's probably higher than what COVID would do to those communities. Is that more or less what you're are thinking?
Yeah, I mean, you know COVID, whenever anyone asks me, especially after there is some like article in the New York Times or something, you know about, oh, Africa did great, Africa did horribly. The reality is, is that we don't know very well because our data collection systems are really weak. But what I can tell you is that the problems that already faced many of these communities were enormous. And so malaria mortality along with, you know childhood pneumonias due to other causes not COVID, you know, deaths in children due to diarrhea, like these account for like hundreds of thousands of deaths every year, and with the disruption of the whole world, including the health systems locally there, you know, we expect to see a significant rise in malaria mortality, you know, in 2020. Like we could be, you know, double the cases, and potentially double the deaths, because these health centers also weren't operational. So people couldn't get treatment, et cetera. So the sort of magnitude of how, you know, illness and logistical disruptions affect these communities, it's, you know, just enormous.
So I could keep asking you questions more or less all day but I would be selfish. So I'm not going to do that, although I do have a few more up my sleeve. What I would like to do is hear from folks who are on this Zoom and what questions you have. So if you have a question, if you could raise your physical hand. It looks like there's a question from Eric. Physical hand or virtual hand. But Eric, if you could unmute and ask your question, that would be great. And it's nice to see you, Eric and I were classmates both MBA ’03, so.
Yep, it's good to see you too. So I used to distribute humanitarian aid and understandably there was a lot of pilfering and a lot of jealousy in amongst people who got what, who didn't get what, how do you combat things like that? Especially in talking about there may be depots where you put materials, those boxes, if I understood correctly. I'll mute myself, go for it.
Well, so actually that was one of the things that we talked about very very early on, as, you know, Baris, John and I were getting together to chat about, you know, all of the variables, all of the things to think about. And so this idea of product leakage, (laughing) was very much in our minds, as you were thinking about it. And so what kind of goes into the modeling scheme is, you know, very small depots that are based around the health center itself. You know certain products have, you know, a lot of outside value.
You know, if we have enough of this product, and we're distributing it in an efficient way, I'm not necessarily sure that there's gonna be this awesome secondary market in the shields, but it's certainly an issue, you know, for other kinds of medications. And so that's always something that needs to be taken into account. We hope that the way that we've designed our kind of local inventory system, that it will be secure, both from leakage and also from the elements, you know, and that we're aware of using the product efficiently, because we also don't want things to expire before they're used.
Amy, just to add to that. This is not the same but sort of related, something we talk about is, we discussed also scenarios, but let me first start with this. It's very possible that we failed to see something, and if anyone feels that way, we would love to hear from you and start worrying about that too, because we really want this to work and work well. So one of the things we were discussing is suppose we can use the truck, so the road, the highway, is in good shape and it's gonna work, but maybe there's some conflict of some sort, could we go to the checkpoint? Would they wanna confiscate these shields, or should we go use pedestrians or would somebody want to steal it? And what's the market value? And things of things of that sort. So these are very much have been on our minds.
We also considered, in a lot of these places, there are different health centers and John mapped them all out working with Amy and people who work with Amy in the area, and we sort of at some point categorize them based on their risk level and how secure the location seems, can we store it there? This and that. In the end for the concerns that you raised, you felt that it is worthwhile to spend some upfront money and kind of build these secure storage facilities and kind of keep the product, even though we think the risk is low, we don't wanna take that chance because the continuity is really important here, right? So this product needs to be continuously supplied. Thank you, Caroline. Caroline, I think you are muted.
Yeah, are there other, so am looking, Eric it looks like you have a follow-up and then…
Yeah, no if anybody else needs to go ahead they can.
Okay, let's hear from Datak.
Hi everyone, I'm Datak from India, and I'm joining (indistinct). I had a question that is revolving around the theme of supplies that we have stored in Africa for example we have a certain demand for a certain product that has already been stored. If you (indistinct) in that store, how it will affect the long-term impact offered in maintaining that product. I was interested in knowing a bit more about how you optimize any of the products that are on demand there, and might have a harmful effect or negative effect if they use too much because of the supply sources.
So the audio was a little tricky, but just to summarize I think you're asking about the difference between the short-term and the long-term impact. Is that right?
Yeah. So the long term and the short term of it, especially with regard to the amenities that we already relocated to that site or which we already have at that site.
Baris and Amy, does that give you enough to go on?
Let me try and understand. So you're thinking of, as we plan things how much you put in there so you have to think about the long-term demand versus short-term demand, that kind of thing?
Yeah. Like if there is a change in demand in the short-term, then how do we optimize the changes in long-term?
So, right. I think this is a great question. So the, what is different in our setting is? Because, again I mean, the things demand may change if the population sizes changing, but otherwise I suspect that the demand is somewhat stable in the sense of her household and so forth. And John knows these better. He's done a demographic analysis of all these 41 villages figured out exactly what the demand would be and did all the, crunched all the numbers. But demand is fairly stable. The issue for us isn't demand is the supply side. Like will I be able to, so sending it turns out sending the truck, if you can, can be the cheapest, you do one delivery to a whole bunch of, and then from then on, you could use other means and so forth. But if that role isn't gonna be available tomorrow, and if I'm going down on the, what do you do? Luckily we can have other ways of doing it like using canoes and boats and pedestrians, motorcycles, at some point we considered drones, and that could still be relevant for a small part of the area, right?
Everything is possible. So, but that's gonna jack up the cost.
So then the whole trade off that John had to go through was to sort of say, these are all future possibilities, and we are smart enough to know that all of these can happen, this is where Amy is data coming into the picture. You get to know the future likelihoods of these. And it's kind of like playing chess, right? You need to look at test steps ahead if you can. And John is able to do that, and then sort of say, okay, taking everything into account, if we were to minimize say the long run average cost or some sort of expected criteria, this is the best action. So I don't know if that gets at your question, if demand was luxuriating, then you would sort of say, okay, how should you adjust those demands based on the trends in demand and that kind of? We could have done it, but I don't think in this scenario it is as relevant. But the supply side is very much relevant to your question.
But there is also another, you know, potential future, you know, issue, right, that we have to consider. If we're able to actually carry out this operational research and we put a product into the hands of people who like the product and feel it works better for them, and kind of achieves their goals, as well as achieving you know, the international health goals like for malaria, but then for whatever reason, you know, we're unable to convince, let's say the international donor community, that it's worthwhile to supply these particular products to certain vulnerable communities that need alternatives. You know, if we give a product for 18 months that people like that works well, that decreases, you know, malaria incidents, but then we're not able to continue providing that product. You know, obviously that's a negative, you know, potential effect. And so that's also part of the reason why we are trying to be as rigorous as we possibly can, because we are specifically trying to make the argument that if it is indeed cost-effective, and we are driving down the malaria mortality rate in some of the highest malaria mortality areas in the world, that then we're able to affect policy. That's really what we need to also be able to do affect policy.
So I would love to pick up on that thread, but there are a number of questions in the chat about the product itself and optimizing the product itself. And so let's turn to both of those for a moment, which are about, you know, did you go through any modeling to come up with the shield solution? And if the key element of the shield is in fact, a coating, could the coding be performed locally? What would be the kind of postponement which would reduce the logistics? And could that supply and provide employment locally? So let's think about the product, and then I'll get back to some of the live hands that I saw raised as well.
So I'll try and be brief in explaining the crazy morass, (laughing) that is a product development in the vector control space for, you know, what people call the base of pyramid or whatever. It's like referring to products for the developing world where, okay, there's a difference between the user, right? And the customer, the payer, right? So that relationship of who is using the product and who is paying for the product, already introduces kind of a layer of complexity into the aid and development world, that we cannot go into here.
But there are many products out there that kill mosquitoes in certain ways that repel mosquitoes in certain ways, there are things that you can build into houses, there's like a kind of wallpaper application, really at the end of the day, what the major constraint is on the deployment of these kinds of products that people might actually prefer and might work better for them in their particular context is exactly like this cost-effectiveness concept. Because for many years, the donor community is accustomed to this now commoditized product, the bed net, that costs a certain unit price. And that, that creates this bound for what the donor community says is kind of willing to pay for. And so you kind of get caught in this like chicken and egg situation, where it's hard for companies to spend all the money on the R and D if they don't think at the end of the day, you know, the donor community is gonna support that product, you know, at the so-called base of pyramid. And so that's part of the work that I've been doing, you know, with, you know, John and Baris, but also kind of outside of that and helping some of the donors to kind of recast the problem in that way.
Some of the issues, right, are just chemistry-constrained as well. Like SC Johnson has been working for a really long time, trying to make that shield as long lasting as it can possibly be, but because of how that that those molecules elute off of the paper and also dealing with things like humidity and, you know, whatever, right, it's actually hard to get a product that will do what it does for longer than it does it for. (laughing)
I mean, I do want to acknowledge though, John's point in the chat, that postponement is a terrific idea, if we could do it, if we could manufacture it there. But I remember going up the SC Johnson facility, of course my highlight was that bug room where they had all these bugs and they were testing these. But I mean clearly, there's a lot of work. We visited the R and D facility, I haven't seen their manufacturing site but if it were a feasible, that would be a fantastic idea, and I don't wanna be a downer but it just seems so challenging. Amy would know this better whether you could actually manufacture it there or not. What are you thinking?
Thank you. So I'm getting some questions in the chat around two things, and I think well, will end with these questions, which are, what do you believe in hope that the world can and will learn from this project? And also what can listeners of today's conversation do to support your work?
Well, I personally want to show rigorously that one can actually cost-effectively serve the communities that are disproportionately suffering from a serious health problem. And by doing so to, I think rise to the challenge of you know, what I think our job is there, right? That you can only pick so much low hanging fruit, before all the fruit is really hard to pick. And we're at that point with malaria control. We have done all of the easiest things that we can do, we've done all the kind of moderate things that we can do, but now what we're we're left with is literally the hardest places to serve, that have the highest mortality figures. So we must meet this challenge, and so my hope is that we can, you know, we can actually begin to show, okay this is how much it costs to serve these people, who, you know, have an unacceptably high mortality rate.
And if I were to add, I sort of would like to see the scale-up in two different ways, two different dimensions. One is obviously to serve other areas which are as challenging and so forth. The other one is, you know, Amy also mentioned diarrhea and other problems. If you're gonna build up the supply chain, you might as well start thinking about other things too. And now the thing is that the characteristics are different. We talked about also water providers and so forth but as it turns out, that's heavier and costlier to carry and this product seemed more suitable our immediate purpose where you could imagine, how with the same logistic chain you can kind of, I mean the prime guy brings both the milk and the other things, right? So because it makes sense. So then how can you explode that economies of scale and broaden this in that way is also something that's of interest to us.
Well, thank you so much, Amy, Baris, and thank you all for joining us. If you're looking for more ways to support this work, or maybe want to embark on a research project of your own, keep an eye out in your inboxes for ways to stay in touch to support Amy's foundation, and its efforts to develop sustainable affordable solutions for delivering healthcare in East Africa. You can also follow the Rustandy Center through our newsletter or social media channels, or email us at RustandyCenter@ChicagoBooth.edu, and if you are interested in this idea of putting research to practice, then save the date for our virtual on-board conference, on May 7th, UChicago economics, Professor John List will be discussing what motivates philanthropy. So thank you so much, and we really appreciate that you joined us today, and thank you, Baris and Amy for this collaboration and the extraordinary work that you're doing.
Thanks for having us, I love working with you guys
Thank you. Same here, thanks everyone.
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