[MUSIC] So Francois, you're a medical doctor. I want to talk about a big social problem that has a medical root which is transmission of HIV from pregnant mothers who are HIV positive to newborns, tell me a little about that problem. >> As many people know HIV/AIDS is a significant global problem, 36.9 million people living with the disease at the end of 2014. And a large portion of the women who discover they're HIV positive is when they're pregnant. The big issue you're referring to is the vertical transmission of HIV from mothers to their newborn children. Which without any intervention would be at about 30 to 50%, so a third to a half of all children would be born with the virus, and the disease, and the significant prognosis that comes with it, if we didn't intervene at all. >> So how do we intervene what do we know about this problem technically and what kinds of things can we do? >> Yeah, thankfully we've spent a significant amount of time researching this and developing anti-retroviral complicated drugs to provide to, both the mother during pregnancy and the child after birth. We know that cesarean section reduces the rate of transmission, and smart choices around feeding. And with all of those interventions and a combination of them in different contexts, we can reduce that transmission rate to around 2 to 3%. >> So this sounds, as you framed it, kind of classically like a complicated problem but solvable with a complicated solution that we can implement, if we have the right pieces in place. How has it worked when the medical system, the healthcare systems have taken the solution into different context and tried to implement it to reduce this problem? >> As you know, the evidence has lead to significant country policies on trying to do this and what we found is, there are many countries still that are not able to reduce their vertical transmission rate below 20%. So they've made marginal improvements. And yet there's been lots of questions around why despite the interventions, despite bringing down the cost and affordability of anti-retrovirals, increasing education around smart feeding choices, that we've not been able to reduce the transmission rate, as quickly as we would like. >> Okay, so we've got a solution, we bring it into a community and there isn't the kind of uptake that we will need to make a dramatic reduction, why? >> Well, we would like to see more mothers have the opportunity to benefit from these protocols. It's not always happening for a range of reasons. I guess the first one could be, they don't have access to a doctor or a nurse who can really take the time to to explain to them the complexity of the treatment protocols. >> Why? >> Well, I know having worked as a doctor, I have probably, about six minutes to see a patient, to explain to them, to give them a diagnosis of a life threatening illness. Probably, after that point no one really hears anything else after you have said that and that's a time when you supposed to explain the whole intervention that is going to to be carried out. >> Okay, and so then they would need to hear about it more and over again. Why don't they? >> Well even if they hear about it over again, the doctors are saying to people, go and make choices about breastfeeding, which might have significant meaning in their community about which breastfeeding choice they have. As we know, HIV has been stigmatized in many communities, and continues to be so, despite the education around it. >> Okay. So I don't know if that was five Why's, but as we start to ask the Why question, we're starting to get to something that looks more like a complex problem obviously. So there's the technical, medical side of this but there's also the healthcare delivery system side. How much time doctors have and nurses have to spend and the resources to do that. There's a cultural side. What different beliefs and attitudes and views are in different families around breastfeeding or on HIV itself around those kinds of things. And there may be a relationship between how people feel about their own power over their own health care and their own sense of how to work with that knowledge. So to me this starts to sound, now moved from a classically complicated problem to a classically wicked or complex problem with many, many different things interacting. And we can at least start to understand why it may be that even with this technical solution, we're not making the inroads that we want to make. So we want to talk a little bit about a very interesting case that we both know. It's South African. It started in South Africa and it's gone to other countries. It's an organization called Mothers2Mothers. And mothers2mothers did a number of things, but their one key innovation, as I understand it, is that they started nurturing mentor mothers. A category, a role that didn't exist before in the system. A mentor mother is somebody who has been through the process, has HIV, has delivered a child, has not transmitted it HIV to the child and has gone successfully through the treatment. And a mentor mother not only helps out with this process, but actually becomes a paid, on-sight part of the medical team, receives continued training. So, becomes both a peer and a professional at the same time. And this is a new innovation within the system. Tell us a little bit more about what does a mentor mother actually do? What's her role? >> Well she walks the journey with the mother who's been diagnosed as HIV positive, and so that six minute intervention suddenly becomes an 18 month intervention of decision making, of support, of contextualizing what this implementation protocol really means in this mother's life. And all the behaviors and interactions with the community, and how she might be able to follow that protocol as closely as possible but adapt it to, really, to her life. And be an inspiration to what a positive outcome might look like. >> As I understand it the outcomes have been quite positive. What's the impact to be? >> Most of those been extremely successful, not only in their own organization and they're now in nine countries, they reach more than 1.3 million women. And they've reduced the vertical transmission rates to 3.7% in countries where the national average lies between 12 and 20%. And it's also been adopted by the World Health Organization as a model for ministries of health to use around reducing mother to child transmission. >> And so we're probably talking hundreds of thousands maybe more babies over time who would have been born with HIV and who aren't, they don't have HIV. So I think, they're a great illustration of a complex approach to a complex system. A complex approach to social innovation. >> So what do you think makes it a complex solution? >> It's a good question and there's no one formula for saying this is a complex solution, this isn't. But I do think there are lot of pieces of this that you'll see across many similarly successful and interesting social innovations that are complexity based. So one thing they've done clearly is they've taken a more holistic look at the system. They're not just looking at the specific medical piece of it in that part of the healthcare system but they're also looking at the community, they're looking at the economics of it. You can't look at the whole system but you can look at more than one piece of it and the more you start to bring in different parts of the system you're thinking, you can start to then connect those maybe in ways that weren't connected before. Connect the community knowledge to medical knowledge to create new solutions that might emerge from that. I think that's a huge piece. I think also, what they've also done really well is, who gets to make decisions and implement, if you can use that word, the solution is a great number of people, we can call it distributed agency. So in a complex system, because every context is different, again like raising a child, you can't have one person or one centralized protocol for making all decisions. So here all of these different mentor mothers are making many decisions every day in the work that they do. And figuring out how do we adopt the knowledge to this specifics of this human being. This human being's context, the family, community, changes in medical knowledge that maybe will keep coming because we're always learning more about this. So they've baked that into their way of working this. And I think the last thing is that they've let their solution be experimental, that we were never going to get to that final solution. As you talked about we're going to keep going and learn new things and let it iterate as it responds to its system. So for me that sounds like a complexity approach. It may not be one ultimate answer, but it's a way to really make in-roads into what looked like a very daunting, almost hopeless problem before you took that complexity away. [MUSIC]
