What happens downstream?: Scott Mattoon's blog

Ordinarily, my Inbox is full of anything but heartwarming emails, but last week I was gratified to receive a photo of four Sun Rays atop health worker desks in Butaro, Rwanda. The photo, sent by Erik Josephson of the Clinton Foundation's HIV/AIDS & Malaria initiative, shows the pilot setup for rural health clinics that former president Bill Clinton envisioned when he made his TED 2007 wish to ...

"... build a sustainable, high quality rural health system for the whole country."

- Bill Clinton, March 2007

Sun provided these Sun Ray 2's and the supporting servers as part of its commitment to support the TED Prize that year. To actually see the Sun gear in situ makes all the planning and logistics and weekly conference calls over the past 18 months suddenly all worthwhile. The site in the photo is one of two pilot locations in which the infrastructure will be tested in live clinical situations over the next month. Pending the results of the pilot, this model infrastructure will be rolled out to an additional 70+ clinics and hospitals across rural Rwanda.

The pilot phase of the project, currently being administered by Partners in Health and The Clinton Foundation is set to begin in the villages of Butaro and Kinoni on Monday. The systems infrastructure, comprised of the Sun Ray 2, Sun Fire X2100 server, and Solaris OS, were selected by the project steering committee to serve up the healthcare worker desktop environment. The selection criteria reflected the goals of the project as well as the relatively austere conditions where the healthcare facilities are located:

• Electricity is scarce and not terribly stable in rural Rwanda, so the Sun Ray 2, which consumes about 4 watts and is an entirely stateless device, is a good fit for the workstation. Attached to each Sun Ray is a low power 15" display which brings the total power consumed by each workstation to less than 25 watts. On the server end, the X2100 is the lowest power server available from Sun. The total electricity demand for the primary IT infrastructure in a typical clinic - 7 workstations (Sun Ray and display), 1 server, 1 network switch - is less than 500 watts.
• These facilities do not have extensive protection from the heat and dust that are common in Rwanda's rural villages, so reliable systems that will hold up to extremes is important. The Sun Fire X2100 is a reliable workhorse with good serviceability. Combine that with the Sun Ray's zero moving parts (except keyboard and mouse) and you have about the most reliable setup possible. Every clinic and hospital will inventory one spare Sun Ray, so if one does fail it's a simple replacement to put that workstation back into service - no installation or configuration required. Just attach it to the network and you're back to treating patients. Spare X2100 servers will be inventoried in Kigale, so a server failure will require that the replacement be dispatched to the facility for replacement.
• Rwanda is a fledgling economy. The ICT infrastructure upon which the healthcare system and other critical social services are built must be sustainable and low cost. Any dependence on proprietary commercial products would effectively impose a tax on growth and leave Rwanda's infrastructure at the mercy of foreign commercial enterprises. So, wherever possible, free and open source products were chosen. The Solaris operating system, the Gnome desktop environment, and the Open Office productivity tools fit the bill, and nicely complement the medical records software to be used in these clinics, OpenMRS.

OpenMRS and Africa's Health Workforce

OpenMRS is an open source application, written in Java, that was conceived by Paul Biondich at the Regenstrief Institute. It is designed expressly to address the need for electronic medical record keeping in the developing world, but also to serve as a framework for building generalized medical informatics systems. The Rwandan government selected OpenMRS as a key component of their healthcare scale up effort.

A few countries in sub-Saharan Africa, Rwanda among them, have set a long range vision for national economic and social advancement. Vision 2020 is Rwanda's development strategy to achieve or even surpass developed world standards for national government, rule of law, education and human resources, infrastructure, entrepreneurship, and agriculture. OpenMRS and the supporting open source and energy efficient technologies from Sun contribute toward the infrastructure as well as the human resource goals of the plan. These tools will help to expand the pool of workers capable of delivering critical forms of healthcare by providing a standard protocol and reference resources to community members and paraprofessionals employed in health worker roles, thereby alleviating dependence on highly trained medical practitioners for routine diagnosis and procedures. Estimates from the development community and the UN indicate it would take more that 20 years for sub-Saharan countries to reach the 2.5 health workers per 1,000 people ratio to be consistent with UN targets, assuming they even had sufficient training capacity to matriculate that many doctors and nurses. Instead, OpenMRS helps to change the equation and make it possible to expand health care services much faster than would be possible in a traditional public health model.

In essence, the four workstations in the photo represent a new model health system, not only for Rwanda, but potentially for many other countries in the developing world.

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Related Reading:

• Can Rwanda's Vision 2020 Succeed? post on WorldChanging.org
• OpenMRS FAQ
• Sun Ray in Health Care (and other Sun Ray success stories)

Here are just a few of the highlights I've had the privilege to experience at TED in Monterey:

Phil Zimbardo prepared Tedsters to become everyday heros by informing us just how closely we dance with evil.  Evoking Solzhenitsyn, who said "The line between good and evil cuts through the heart of every individual," Zimbardo's research reveals how susceptible we all are to falling in with Bad Apples.  But we're able to resist it best when we're not in a Bad Barrel, i.e., the situations and institutions we inhabit must foster cooperation not separatism, empathy not blame.  I.e., the opposite of the conditions in Abu Graib pre-scandal.

Irwin Redlener prepared us for survival in the wake of a nuclear attack by elucidating a few relatively unknown tips:  (1) post blast radioactivity within a mile or so of the blast is lethal on the ground, so get shelter below ground or on the 10th floor or above, (2) know the prevailing wind direction (and ideally the actual wind direction at time of blast) and head perpendicular or away from it,  (3) don't rely on the government or other government preparedness programs to protect yourself.  They're not ready to deal with it, and (4) keep your mouth open so your sinuses don't burst in the aftershock of the blast.

Samantha Power prepared us to recognize heros who embody the knowledge so precious to dealing with today's most difficult challenges by giving tribute to champions like Sérgio Vieira de Mello, and reminding us to seek them when working to avert social atrocities and humanitarian crises.  She put American pride on notice with a reminder that our "Never again" ethos was nowhere to be found during the Rwandan genocide.

A brief "trailer(?)" for Pangea Day debuted to the delight of Tedsters.

And then there were the Prize Winners:

Neil Turok, whose dream is that the next Einstein will be African.  He's building a model for higher science education in Africa with the AIMS school, delivering RICH (Relevant, Innovative, Cost Effective, High quality) education in major African countries.

Dave Eggers, founder of 826 Valencia and merchant to buccaneers.  His model for neighborhood driven afterschool tutoring in the back of a kids emporium is being imitated all over America, and has even sprung up in Dublin.

Karen Armstrong, author and scholar of comparative religions.  Her wish is perhaps the most audacious TED wish to date, which is has something to do with getting Jews, Muslims, and Christians together on matters of universal justice and respect, but I'm a little vague on the details.  I thinks she wants some help with that part. 

Anyway, Karen and the rest made a believer out of me.

Sitting in the Is Beauty Truth? session at TED2008 today, I am reminded of a phone conference with TED Curator Chris Anderson last fall to bring him up to date on the status of one of the previous year's TED wishes.

When Sun wrapped up its formal role in developing the Open Architecture Network (OAN) it handed over a sustaining challenge to the site's owner and community leader, Architecture for Humanity (AFH).   When TED Curator Chris Anderson asked Sun why the TED Prize winner was left in a lurch I gave a short answer, "It was primarily due to reasons of expediency".  In actual fact, Sun never walked away from AFH.  Sun was, and continues to be, committed to their success and continues to be involved.  As of today, we now we see a clear path to a sustaining model that leverages the Drupal community and frees AFH from the dependence cycle it was caught in with Sun.  I look forward to bringing that good news to Chris before the conference wraps up on Saturday.

The first step on this path is to refactor the site such that it runs on an unadulterated Drupal core.  To do that AFH and Sun have contracted with CivicActions to migrate the OAN from a hacked Drupal 4.7 to a clean Drupal 5.X.  (It was the hacking aspect that I explained away to Chris Anderson as "expediency".  Corners were cut, compromises were made, but AFH's and TED's primary goal, to launch the site at TED2007, was achieved.  Incidentally, of the three TED2006 prize winner, only AFH's wish was realized by TED2007.)  CivicActions won the bid to perform the migration by doing a professional and efficient assessment of the OAN's current state and the effort required to bring it up to the high standards of a showcase Drupal site.

My next few posts will describe the process of setting up this development environment as we open Chapter 2 in the OAN's odyssey.  I'll describe how we use OpenSolaris to enable efficient development, testing, and deployment for multiple contributors working on multiple tasks and timelines.

For more on why OpenSolaris was chosen as the development and deployment platform for the OAN, see this article on the Sun Developer Network, and this brief interview.