As with most difficulties in global health care, lack of adequate technology is not the biggest problem. We already have a great warming technology: a mother’s skin. But even in high-income countries we do not consistently use it. In the United States, according to Ringer, more than half of newborns needing intensive care arrive hypothermic. Preventing hypothermia is a perfect example of an unsexy task: it demands painstaking effort without immediate reward. Getting hospitals and birth attendants to carry out even a few of the tasks required for safer childbirth would save hundreds of thousands of lives. But how do we do that?
The most common approach to changing behavior is to say to people, “Please do X.” Please warm the newborn. Please wash your hands. Please follow through on the twenty-seven other childbirth practices that you’re not doing. This is what we say in the classroom, in instructional videos, and in public-service campaigns, and it works, but only up to a point.
Then, there’s the law-and-order approach: “You must do X.” We establish standards and regulations, and threaten to punish failures with fines, suspensions, the revocation of licenses. Punishment can work. Behavioral economists have even quantified how averse people are to penalties. In experimental games, they will often quit playing rather than risk facing negative consequences. And that is the problem with threatening to discipline birth attendants who are taking difficult-to-fill jobs under intensely trying conditions. They’ll quit.
The kinder version of “You must do X” is to offer incentives rather than penalties. Maybe we could pay birth attendants a bonus for every healthy child who makes it past a week of life. But then you think about how hard it would be to make a scheme like that work, especially in poor settings. You’d need a sophisticated tracking procedure, to make sure that people aren’t gaming the system, and complex statistical calculations, to take prior risks into account. There’s also the impossible question of how you split the reward among all the people involved. How much should the community health worker who provided the prenatal care get? The birth attendant who handled the first twelve hours of labor? The one who came on duty and handled the delivery? The doctor who was called in when things got complicated? The pharmacist who stocked the antibiotic that the child required?
Besides, neither penalties nor incentives achieve what we’re really after: a system and a culture where X is what people do, day in and day out, even when no one is watching. “You must” rewards mere compliance. Getting to “X is what we do” means establishing X as the norm. And that’s what we want: for skin-to-skin warming, hand washing, and all the other lifesaving practices of childbirth to be, quite simply, the norm.
Reactions that I’ve heard both abroad and at home have been interestingly divided. The most common objection is that, even if it works, this kind of one-on-one, on-site mentoring “isn’t scalable.” But that’s one thing it surely is. If the intervention saves as many mothers and newborns as we’re hoping—about a thousand lives in the course of a year at the target hospitals—then all that need be done is to hire and develop similar cadres of childbirth-improvement workers for other places around the country and potentially the world. To many people, that doesn’t sound like much of a solution. It would require broad mobilization, substantial expense, and perhaps even the development of a new profession. But, to combat the many antisepsis-like problems in the world, that’s exactly what has worked. Think about the creation of anesthesiology: it meant doubling the number of doctors in every operation, and we went ahead and did so. To reduce illiteracy, countries, starting with our own, built schools, trained professional teachers, and made education free and compulsory for all children. To improve farming, governments have sent hundreds of thousands of agriculture extension agents to visit farmers across America and every corner of the world and teach them up-to-date methods for increasing their crop yields. Such programs have been extraordinarily effective. They have cut the global illiteracy rate from one in three adults in 1970 to one in six today, and helped give us a Green Revolution that saved more than a billion people from starvation.
In the era of the iPhone, Facebook, and Twitter, we’ve become enamored of ideas that spread as effortlessly as ether. We want frictionless, “turnkey” solutions to the major difficulties of the world—hunger, disease, poverty. We prefer instructional videos to teachers, drones to troops, incentives to institutions. People and institutions can feel messy and anachronistic. They introduce, as the engineers put it, uncontrolled variability.
But technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread. Mass media can introduce a new idea to people. But, Rogers showed, people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.
This is something that salespeople understand well. I once asked a pharmaceutical rep how he persuaded doctors—who are notoriously stubborn—to adopt a new medicine. Evidence is not remotely enough, he said, however strong a case you may have. You must also apply “the rule of seven touches.” Personally “touch” the doctors seven times, and they will come to know you; if they know you, they might trust you; and, if they trust you, they will change. That’s why he stocked doctors’ closets with free drug samples in person. Then he could poke his head around the corner and ask, “So how did your daughter Debbie’s soccer game go?” Eventually, this can become “Have you seen this study on our new drug? How about giving it a try?” As the rep had recognized, human interaction is the key force in overcoming resistance and speeding change.