Welcome to Fixes.
This is a series about solutions, or potential solutions, to real world problems. It focuses on the line between failure and success, drawing on the stories of people who have crossed it.
Most of us tend to be better informed about problems than solutions. This presents two challenges: if we rarely hear about success when it occurs, it’s hard to believe that problems can, in fact, be solved. Also, knowledge about how to solve problems ends up being concentrated in too few hands. It needs to circulate more broadly so that it can be applied where needed.
We are both journalists who have spent more than two decades reporting on social problems around the world, and where possible, exploring new models to address them. Here, we’ll be looking at examples of success in fields such as health care, education, employment, political change and environmental protection. The projects can be as specific as fixing motorcycles or as broad as improving the way we finance vaccines globally. Examples will come from all over — the poorest parts of Africa and South Asia, but also middle-income countries like Mexico and Poland and rich ones like Canada and the United States. In each case, we will look at what the people behind them did differently — what led to success in a world where plans so often end in disappointment. And we will explore what we can learn from their experiences.
Today, we will examine one solution to a vexing problem: many diseases that we know how to prevent and cure remain widespread. For nearly all of human history, lives were short and miserable because there was little anyone could do about disease. Now we know what to do. The science is there. The technology is there. But we have a different problem ─ a happier one, but no less challenging: how do we get these interventions to people everywhere? And this problem doesn’t just apply to health care, it applies to almost every modern good or service, whether it’s education, energy, clean water or job opportunities. As the science fiction writer William Gibson has said, “The future is here ─ it’s just not evenly distributed.”
That’s why we’re beginning Fixes with the story of a health assistant named Tsepo Kotelo, whose job is to take care of people in remote mountain villages in the Maseru district of Lesotho. Kotelo’s story shows the critical need for something not usually on the global to-do list for Third World health: motorcycle maintenance.
Lesotho has some of the world’s highest rates of AIDS and tuberculosis, and much of Kotelo’s time is spent counseling and testing people for these diseases, giving talks about AIDS prevention, and helping people stick to their treatment plans and deal with side effects. He also checks the water supply, helps villagers improve sanitation, weighs and immunizes babies, examines pregnant women and treats basic diseases.
Until 2008 Kotelo could visit only three villages a week, because he had to reach them on foot, walking for miles and miles. But in February of that year, Kotelo got a motorcycle ─ the best vehicle for reaching rural villages in Africa, most of which are nowhere near a real road. Just as crucial, he was given the tools to keep the bike on the road: he received a helmet and protective clothing, he was taught to ride and trained to start each day with a quick check of the bike. His motorcycle is also tuned up monthly by a technician who comes to him. Now, instead of spending his days walking to his job, he can do his job. Instead of visiting three villages each week, he visits 20. Where else can you find a low-tech investment in health care that increases patient coverage by nearly 600 percent?
Kotelo’s four colleagues also received motorcycles, and now every village in the Maseru district has health care. The area also now has five motorcycle couriers who drive blood or sputum samples from villages to local laboratories ─ particularly important to test for H.I.V. and TB, and to see if the medicines are working. The couriers get the same training and gear as Kotelo, plus special temperature-controlled, vibration-smoothing backpacks. Before, samples were packed in plastic bags and walked to clinics. They would usually arrive late, boiled or shaken beyond use ─ if they got there at all.
The motorcycles come from the Elton John AIDS Foundation, but the maintenance comes from Riders for Health, a British-based organization founded by a husband and wife team, Barry and Andrea Coleman. The idea began in 1988, during a visit by the American motorcycle racing star Randy Mamola to Somalia. Mamola had given a sizeable donation to Save the Children, and had been invited to see its work in person. He asked Andrea Coleman, who did public relations work for him and helped him raise money for charity, to come along. She had young children and declined, but suggested Mamola take her husband, Barry, who wrote about motorcycle racing for The Guardian newspaper.
It was the first of several trips for Mamola and the Colemans. In Somalia, they saw a woman in distressed labor being pushed towards the health clinic in a wheelbarrow. They visited villages and heard that no one had ever come to vaccinate children. Yet they also saw a graveyard of dead motorcycles and ambulances behind the clinic, some of them discarded for want of a $3 part and a little know-how. “Some of them were relatively new,” said Andrea Coleman. “This was crazy. It’s been 100 years since the internal combustion engine was invented and nobody knew how to deal with these vehicles. What a waste of money and lives.” Today the Colemans run Riders.
There’s nothing new about donating vehicles for health care in Africa. Many organizations do it. But often these vehicles fall apart. Barry Coleman says that unmanaged, a vehicle in Africa will usually have a major breakdown after 8 months of use and be junked entirely by 15 months. This is a classic problem in development: everybody wants to play the white knight coming to the rescue with the quick fix — the water pump, the $100 laptop, the motorcycle. But the tougher challenge is developing a cost-effective system to keep things working.
In some countries, Riders provides vehicles ─ for example Gambia’s health system leases all its vehicles from Riders. But what makes Riders different is that in all of the seven countries it works in, it focuses on keeping the vehicles running. Riders charges a fixed cost of about 18 cents per kilometer for motorcycles, which includes fuel, and keeps vehicles in constant use for years with no breakdowns. It trains and hires local technicians to do monthly tune-ups. The predictable fees help governments and aid groups incorporate maintenance in their budget planning. Riders currently manages about 1,200 motorcycles, ambulances and four-wheel drive vehicles used for health care in Africa. The vast majority are motorcycles ─ even some ambulances are motorcycles with sidecars.
We’re not suggesting that motorcycles will solve Africa’s health problems ─ not even its health delivery problems. The continent is facing a severe shortage of health care workers. (Thousands are poached each year by wealthy countries; we’ll write about some fixes for this in future columns.) But it’s within easy reach to multiply the scope and efficiency of the people who are already on the ground.
We already mentioned that Tsepo Kotelo’s motorcycle allows him to serve almost seven times as many villages as before. Kotelo can also respond to emergencies, so he can provide better care as well as more of it. And visiting villages more frequently, he can catch illnesses in their early stages or prevent them entirely. A woman with a breach baby can make it to the hospital in time — by sidecar ambulance, no wheelbarrow necessary. People now give sputum samples for TB diagnoses because they trust that their samples will actually reach the laboratory unspoiled. All these changes save lives.
Dependable transport could revolutionize more than health care. In poor countries, rural schools often lack teachers, who don’t want to live in villages. If they could commute to work by motorcycle, more village children would be educated. Additionally, water and electrification projects remain stalled across Africa because district government offices don’t even have one bike to make site visits.
Riders dramatizes the importance of paying attention to the scruffy and mundane parts of a system, especially delivery. Businesses understand this. If Federal Express didn’t maintain its trucks, it would go bankrupt. The same applies to social interventions. It doesn’t matter how many billions have been spent on life-saving drugs or how well-trained the nurses are if a clogged fuel line prevents the treatments from reaching the patient.
Riders for Health’s focus on motorcycle maintenance is an example of the creative and practical ideas we look forward to debating with interested readers as this column develops. We hope these ideas will also lead to discussions of the big questions about social change.
We look forward to your comments — and also hearing about the creative fixes you’ve come across.