Crisis had been a feature of capitalism even before Marx gave it its name. The abundance of theories intended to explain crisis — from Marx to Keynes and beyond — demonstrates the centrality of disruption to production and profit.¹ And, despite these many theories, cycles of crisis continue to mark our history: the Great Depression, the energy crises of the 1970s, the bust of the dot-com bubble, and the financial crisis we call the Great Recession.

The shock of crisis can give way to something better. The deprivation of the Great Depression ended in the social contract of the New Deal. The energy crisis gave birth to the modern environmental movement. The dot-com bust sowed the seeds for the transformative technologies that connect us today. The slow recovery and persistent inequality that followed the end of the Great Recession in 2008 suggest that we do not yet know what may come of this latest crisis.²

The future of business must overcome the social, environmental, and economic challenges of these crises. The transformation of business begins with the personal transformation³ of the leaders of companies, a conscious commitment to build a business as a participant in an ecosystem to endure disruption and move beyond profit to purpose.⁴ These leaders must find a way to meet the needs of all stakeholders, not just investors or shareholders by managing multiple bottom lines that track the impact on the well being of employees; the communities we touch; the environment and the resources we use; the crises we prevent; the services we provide: the health of the public.

When leaders consciously design their businesses to elevate society first, they help foster a more equitable and sustainable environment that promotes development and empowerment, builds capacity, and strengthens social networks and trust within a population. Positive social impact works well when it is participatory; it increases understanding of change and capacities to respond to change; it seeks to avoid and mitigate negative impacts and to enhance positive benefits; it engages in sustainable practices; it improves the skills of its workers, and it enhances the lives of vulnerable and disadvantaged people.^5,6   

Public health is everyone’s responsibility, and no one is better equipped with the platform, the resources, and the access to markets than the business community. By infusing public health principles into a corporation’s mission and values, we all benefit.

1. Shaikh, Anwar. “An introduction to the history of crisis theories.” US capitalism in crisis (1978): 219-241.
2. “IMF fears ‘social explosion’ from world jobs crisis – Telegraph.” 2011. 30 Apr. 2016 <http://www.telegraph.co.uk/finance/financialcrisis/8000561/IMF-fears-social-explosion-from-world-jobs-crisis.html>
3. “Whole Foods’ John Mackey: Self-awareness on Aisle 5 …” 2014. 30 Apr. 2016 <http://fortune.com/2013/03/08/whole-foods-john-mackey-self-awareness-on-aisle-5/>
4. “Conscious Capitalism” Is Not an Oxymoron.” 2014. 30 Apr. 2016 <https://hbr.org/2013/01/cultivating-a-higher-conscious>
5. Esteves, Ana Maria, Daniel Franks, and Frank Vanclay. “Social impact assessment: the state of the art.” Impact Assessment and Project Appraisal 30.1 (2012): 34-42.
6. “CSV Explained – Institute For Strategy And Competitiveness …” 2014. 1 May. 2016 <http://www.isc.hbs.edu/creating-shared-value/csv-explained/pages/default.aspx>

I recently took the position of Director of Clinical Research at Preciva, an Oregon registered benefit company whose mission is to see that every woman and girl has a chance to live free of cervical cancer. Our goal is to make critical preventive screening affordable for women around the world and our first product is a field-portable electronic device designed to radically reduce the cost and increase the accessibility of cervical cancer screening.

Cervical cancer kills over 288,000 women annually, nearly 85% of them in low and middle income countries (LMICs).¹ According to a report by the Cervical Cancer Free Coalition, approximately 26% of all cervical cancer deaths occur in India, accounting for more than any other country.² Despite this significant burden of disease, India has no existing national cervical cancer screening program. Screening efforts are localized, opportunistic, and in many regions limited by the lack of available pathology resources and trained healthcare providers.³

It’s a troubling fact that the single greatest determinant of cancer survival is where you live. And for decades, complex comprehensive screening programs and cancer care have been neglected in areas of the world with weaker health systems, such as parts of India or in many nations of sub-Saharan Africa.⁴ However, it was also once thought that antiretroviral treatment and multi drug resistant tuberculosis therapy were not cost effective and too impractical to warrant wide scale administer in LMICs. Success in the fields of TB and HIV control have come mainly from coordination of financing and procurement strategies that have helped to streamline supply chains for therapeutics and diagnostics as well as integrate these advances into national agendas.⁴ The Clinton Health Access Initiative, for example, substantially increased access to generic HIV drugs and the government of South Africa drastically improved TB screening efforts through massive government-led campaigns.^5,6

Despite the attention and advances in HIV, TB, and malaria, more deaths occur worldwide due to cancer than in these three diseases combined.⁷ However, donor funding available for cancer prevention and treatment is vastly disproportional to the growing worldwide need as this public radio international infographic displays.

Barriers to the advancement of a global cancer strategy were a major focus at the Global Oncology Symposium at Fred Hutch Cancer Center in Seattle WA, “Making Cancer a Priority in Global Health.” This meeting brought together leaders and stakeholders in oncology, public health, industry, and foundations to discuss the current state of cancer prevention, screening, diagnostics, and treatment in a global context.

Through several presentations and panels, speakers worked towards defining priority areas in cancer research, advocating to build capacity in LMICs, and identifying gaps in knowledge and opportunities in funding. Much of the message was focused on looking beyond categorical programs and striving for broader system change. It’s widely acknowledged that in order to tackle global caner, we need better data systems for tracking, robust education on screening and prevention, greater investments in the healthcare workforce, and thorough program evaluation to understand what works and what does not.

The United Nations General Assembly will adopt the 2015 sustainable development agenda in September 2015 and this declaration is expected to include a strong stance on the reduction of non-communicable diseases. While this agenda is likely to result in new funding streams to combat cancer, it is critical that we build on the successes of HIV and TB and learn from what did not work well. I previously wrote about the unintended consequences of PEPFAR in Uganda, where despite its undeniable successes in improving access to anti retroviral therapy, this $15 billion investment also fostered the development of narrow disease-focused private programs and non governmental organizations that put strain on the greater public health system. The challenge to making cancer a global priority will be to invest in innovations that are reducing costs, improving access, and filling knowledge gaps while also supporting and strengthening the workforce and institutions needed to incorporate these advances into the broader health system. Further, countries must foster the political will to adopt screening and prevention initiatives as national policy and extend resources to link screening programs with treatment options.

At Preciva we hope to be part of the solution to improve access to affordable screening in areas of the world where cancer is disproportionally affecting the most vulnerable, starting with India, a country with a significant burden of cervical cancer. We strive to take a multi faceted approach through the development of better technology, the implementation and evaluation of our device, and by building partnerships with advocates and policymakers to integrate cervical cancer screening into a broader political landscape. To achieve these goals we are focused on initial clinical validation and design evaluation with partners at Apollo Institute of Medical Sciences and Research and St Johns Medical College in Hyderabad and Bangalore, India. Additionally we will work with Swasti, a Bangalore based international health resource center specializing in the social and management aspects of public health to develop an advocacy strategy for developing national and community-based cervical cancer screening programs and appropriate links to treatment opportunities. Through this research, Preciva strives to ensure that every woman has an equal chance to live free of cervical cancer.

1. Singh M, Ranjan R, Das B et al. Knowledge, attitude and practice of cervical cancer screening in women visiting a tertiary care hospital of Delhi. Indian J Cancer. 2014; 51(3) 319-323.
2. http://blogs.wsj.com/indiarealtime/2013/05/10/india-has-highest-number-of-cervical-cancer-deaths/.
3. Nair M, Varghese C & Swaminathan R. Cancer: Current scenario, intervention strategies and projections for 2015. World Health Organization NCMH Background Papers Burden of Disease in India. 2015.
4. Farmer P, Frenk J, Knaul F et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet 2010; 376: 1186–93.
5. Waning B, Kaplan W, King A et al. Global strategies to reduce the price of antiretroviral medicines: evidence from transactional databases. Bulletin of the World Health Organization2009; 87:520-528.
6. http://allafrica.com/stories/201503250851.html
7. Lozano R,Naghavi M, Foreman K et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.  2012 Dec 15;380(9859):2095-128.
8. http://www.pri.org/stories/2012-12-02/global-cancer-infographics

Last month I participated in the Hult Prize, a start-up accelerator competition funded by the Clinton Global Initiative and Hult International Business School to identify and launch social businesses that tackle the toughest health and development problems faced by the world’s most vulnerable. This year’s challenge was to design a business plan for a sustainable and scalable social enterprise to address non-communicable diseases of 25 million people living in urban slums by 2019.

 300 teams selected from 10,000 applicants in over 150 countries pitched their ideas at the Hult Prize regional finals on March 7 and 8 in Boston, San Francisco, London, Dubai, Shanghai and Sao Paulo. The Hult prize competition was initially designed for MBA students and aspiring entrepreneurs but in its 5^th year, the challenge has grown to also draw participants from diverse backgrounds including public health, medicine, engineering, public policy, environmental science and others.

 As a public health graduate of the University of Wisconsin School of Medicine and Public health I teamed up with 4 MBA students from the University of Wisconsin to design an ambitious plan to improve access to palliative care for urban slum dwellers. The palliative care landscape is extremely complex and opioids are some of most effective analgesic medications for the management of severe pain in end of life care. Several opioids are included on the World Health Organization list of essential medicines; however, due to restrictive regulations, gaps in medical knowledge and supply chain challenges, approximately 80% of the world’s population lacks adequate access to opioid medications for pain control.¹ Our team’s goal was to develop a system that would better track and control opioid distribution with the hope of improving forecasting and country level supply. While we came up short at the regional finals in San Francisco, this experience gave us the opportunity to work closely with the UW Pain & Policy Studies Group and the group’s director Dr. Jim Cleary, a global leader in worldwide palliative care reform.

 In the public health community, the prevention of non-communicable disease is paramount for improving the health and well-being of the world’s population. However within the confines of this competition that focused only on treatment and care, the fundamental concept of prevention was off the table. As a health science researcher I am accustomed to attending conferences and meetings with likeminded people. The Hult prize experience, however, created a unique opportunity to bring together individuals from diverse backgrounds who all approach global health and development problems in very different ways.

I found that the nature of the competition highlighted an observed tension in global health between the desire to quickly address an urgent need with the value of an evidence based and evaluated intervention that requires great amounts of time and resources. The concept of an accelerator competition was quite new to me. In the grants based work of academic research, awards come when you have the science to back up your idea and clear roadmap of how to get there. The Hult prize judges, however, were looking for a  “million dollar idea” that they could throw support behind and help you figure out how to get there at a later time. For some teams, including my own, the product of this was a business model based on assumptions, speculation, and imagined benefit.

 However not all ideas were conceived with the Hult Prize in mind. Worldwide Innovative Health care or WiCare, a women-led team from MIT presented a simple and easy to manufacture negative pressure wound pump to treat open wounds and infections that cause severe complications and sometimes death. This team is already well on their way to operating a successful business and has support form Massachusetts General Hospital, Partners in Health and Médecins Sans Frontières. WiCare’s pitch to the Hult judges was polished; they had an idea, a plan, efficacy data, and evidence of a clear demand for their product. They effectively convinced the judges that with Hult Prize support, their wound pump could scale up to improve the health of millions across the globe and they won the San Francisco regional round. WiCare along with 5 other teams will participate in the summer accelerator program. All six teams will meet in NYC on September 22, 2014 at the Clinton Global Initiative annual meeting and pitch their finalized ideas in front of President Clinton and other leaders in global health and innovation. One team will walk away with $1M in start-up funds.

 Many non-governmental organizations (NGOs) are already under pressure to perform in an increasingly competitive funding environment and numerous well-intended NGOs close up shop as soon as the funding dries up. The global health and development landscape needs to shift away form donor-based organizations to sustainable social enterprises to reduce or eliminate dependence on cash injections. And while Hult offers only one prize per year, this event fosters an environment where passionate individuals with diverse perspectives on health and innovation gather to debate a better way to improve health across the globe.

1. WHO Global Atlas of Palliative Care at the end of life, 2014

Medical anthropologist and physician, Claire Wendland’s A HeartFor the Work traces the development of medical students from their introduction into the University of Malawi, College of Medicine, through their preclinical training and into their lives as practicing physicians. Medical training is a distinct period of socialization that shapes the values and identities of trainees and influences how they will eventually practice medicine. While there is extensive literature on this topic in the developed world, there is a gap in the assessment of experiences of medical trainees from developing countries. Systemic injustices endemic in the global health community prevent biomedicine in sub-Saharan Africa from fully transitioning away from its colonial origins. When evaluating the lived experiences of young Malawian medical students, Wendland argues that medical training in a resource poor settings produces medical professionals whose moral attitudes are fundamentally distinct from clinicians in the developed world.

Doctors and scientists tend to view the stories they tell as objective, neutral, and transcending of culture. However, medicine and experimental results are hard to disentangle from the social and cultural structures that produce them. If knowledge is neutral, then how that knowledge is translated into practice and by whom, can reveal power structures and values in a society. How is the moral development of medical trainees shaped when the resources needed to practice biomedicine are unavailable? How are attitudes influenced when the lives of those who work in medicine are plagued by the same hardship and system failure that produces their patient’s suffering? Through rich narrative, detailed description, and personal anecdotes, Wendland offers insight to these questions.

In Malawi, traditional healing practices; witchcraft; colonization; the introduction of biomedicine; medical missions; and the creation of the first medical school represent a complex legacy of transnationalism and political struggle. The first Malawian medical students began their transformation into doctors at a time where the practice of biomedicine was seen as a tool for Africans moving towards independence and self-determination. The role of a physician was regarded as elite, humanitarian, and authoritarian and the class of Malawian medical students sampled in this work are mostly male, Christian, urban, educated, and unrepresentative of the country’s population. Primary motivations for entering medicine included altruism, pragmatism, and a sense of calling. Both the homogeneity in the group as well as the exceptionalities of the student population influenced how they came to view their role and their patients.

In chapter four, “Seeing Deeply and Seeing Through in the Basic Science Years,” Wendland describes how the medical students transform during the first few years as they began rigorous basic science training in their medical curriculum. Pressures to pass difficult barrier exams forced some students to choose between failing and cheating. Anatomy and physiology lessons gave students a new understanding of the body and many challenged traditional beliefs, giving them a sense of distinction from the general population and an identity as a scientist.

As the students transitioned into clinical trainees in “The World Made Flesh: Hospital Experience and Clinical Crisis,” Wendland describes how the social and economic realities of patients are fully intertwined with the workforce in the Malawian hospital. Staffing shortages and lack of basic supplies challenged student’s once held beliefs about the impact they may have on their patients and their community. As the developing clinician is confronted with nearly unbearable clinical challenges, hope and empowerment turned to doubt, anger, and resentment.

Wendlends argues that medicine has a moral economy that is constantly renegotiated based on social and economic conditions and those involved. Geographic, environmental, social, and economic determinants of population health vary vastly across the globe. Medical training cannot be regarded as universal, however, medical schools become accredited and physicians gain prestige by meeting “international” standards. These metrics, imported from the resource rich settings often include the number of papers published in elite journals, grant dollars funded, and awards won. Practically relevant matters like the number of lives saved and successful births under inadequate conditions do not count towards these standards. Therefore, the motivation to produce physicians of “international” caliber has left schools continuing colonial traditions relying on external exams and research “collaborations” that serve the interest of those seeking publication and funding over local needs.

While the modeling of standards imposed on medical institutions may stunt the progression of the Malawian health system, Wendland’s work reveals an inspiring key distinction between the Malawian students and doctors and their counterparts in the developed world. When clinicians in resource rich settings are pushed to the point of cynicism, they tend to become angry with their patients citing disgust and frustration with an individual’s treatment noncompliance, poor lifestyle habits, or an unwillingness to change behavior. The anger that Malawians feel is instead directed towards the inadequacies in the system claiming to care for their patients. While many clinicians in the developed world cope with this cynicism through emotional detachment or hardening, young Malawian doctors cling to emotion describing the “heart” needed to endure their work. This sense of solidarity with their patients is fundamental to the development of the Malawian doctor.

“When these doctors -to- be talked about their work, they used spirit (or love or heart) for the work interchangeably with spirit (or love or heart) for the people: ‘the people’ were Malawians, and the people were the work.”

Uganda has one of the highest maternal mortality ratios in the world where 435 mothers are estimated to die for every 100,000 live births.¹ This compares to 16 per 100,000 in developed countries highlighting a vast global disparity and a need for strengthening of the Ugandan health system. Accurate characterization of the problem is essential for developing efficient policy to address system-wide deficiencies. The maternal mortality estimates we rely on are limited by variability, periodicity, and their wide confidence intervals.²

In recent years, researchers and developers have taken an interest in mobile communication technology to improve health-related services in the developing world. A huge surge in mobile phone (mHealth) projects across sub-Saharan Africa has emerged as mobile phones are penetrating the region in ways that healthcare infrastructure has not. Since public health and healthcare practitioners strive to provide and capturte accurate information in a timely fashion, mobile phones are an obvious message delivery and data collection tool.

As part of last summer’s family planning series in the Lancet, the authors called  for “infectious disease surveillance approaches” applied to maternal health. If every maternal death is reported in real-time via mobile phones then accurate, real-time, geographically stratified surveillance data could replace periodic estimates and improve data quality. Monitoring and evaluating the burden of maternal death and serious pregnancy complications is a key step in achieving Millennium Development Goal 5.

With the fast proliferation of mHealth projects across Uganda, the Ministry of Health (MoH) now recognizes significant gaps between these interventions and their outputs, evaluations, and results. To streamline and improve efficiency in this fast growing field, the MoH now requires approval before implementation of an mHealth project. Endorsement from policymakers and coordination between government, healthcare providers, researchers, and technology developers is essential to ensure interventions align with the objectives and priorities of the local stakeholders.

Investigators at the University of Wisconsin School of Medicine and Public Health and Mbarara University of Science and Technology are designing a pilot study to initiate a maternal health surveillance system in rural Uganda using mobile phones that connects output data with local decision makers. Here are a few words on the proposal from Ajay Sethi, PhD at the Wisconsin Global Heath Institute’s 2013 symposium.

1. World Health Organization: Maternal Mortality Fact Sheet May 2012. http://www.who.int/mediacentre/factsheets/fs348/en/index.html accessed July 20, 2012.
2. Gilmore K, Gebreyesus TA. What will it take to eliminate preventable maternal deaths? Lancet July 10, 2012, Vol 380.