The Checklist Manifesto_ How to Get Things Right - Atul Gawande [38]
The roots of these problems were deep and multifactorial. Besides inadequate water and sewage systems, illiteracy played a part, hampering the spread of basic health knowledge. Corruption, political instability, and bureaucracy discouraged investment in local industry that might provide jobs and money for families to improve their conditions. Low global agriculture prices made rural farming life impossible, causing hundreds of thousands to flock to the cities in search of work, which only increased the crowding. Under these circumstances, it seemed unlikely that any meaningful improvement in the health of children could be made without a top-to-bottom reinvention of government and society.
But a young public health worker had an idea. Stephen Luby had grown up in Omaha, Nebraska, where his father chaired the obstetrics and gynecology faculty at Creighton University. He attended medical school at the University of Texas Southwestern. But for some reason he was always drawn to public health work. He took a CDC job investigating infectious outbreaks in South Carolina, but when a position came open in the CDC’s Pakistan office he jumped to take it. He arrived in Karachi with his schoolteacher wife and began publishing his first investigations of conditions there in the late nineties.
I had spoken to him once about how he thought through the difficulties. “If we had the kinds of water and sewage systems we’ve got in Omaha, we could solve these problems,” he said. “But you have to wait decades for major infrastructure projects.” So instead, he said, he looked for low-tech solutions. In this case, the solution he came up with was so humble it seemed laughable to his colleagues. It was soap.
Luby learned that Procter & Gamble, the consumer product conglomerate, was eager to prove the value of its new antibacterial Safeguard soap. So despite his colleagues’ skepticism, he persuaded the company to provide a grant for a proper study and to supply cases of Safeguard both with and without triclocarban, an antibacterial agent. Once a week, field-workers from HOPE fanned out through twenty-five randomly chosen neighborhoods in the Karachi slums distributing the soap, some with the antibacterial agent and some without. They encouraged people to use it in six situations: to wash their bodies once daily and to wash their hands every time they defecated, wiped an infant, or were about to eat, prepare food, or feed it to others. The field-workers then collected information on illness rates among children in the test neighborhoods, as well as in eleven control neighborhoods, where no soap was distributed.
Luby and his team reported their results in a landmark paper published in the Lancet in 2005. Families in the test neighborhoods received an average of 3.3 bars of soap per week for one year. During this period, the incidence of diarrhea among children in these neighborhoods fell 52 percent compared to that in the control group, no matter which soap was used. The incidence of pneumonia fell 48 percent. And the incidence of impetigo, a bacterial skin infection, fell 35 percent. These were stunning results. And they were achieved despite the illiteracy, the poverty, the crowding, and even the fact that, however much soap they used, people were still drinking and washing with contaminated water.
Ironically, Luby said, Procter & Gamble considered the study something of a disappointment. His research team had found no added benefit from having the antibacterial agent in the soap. Plain soap proved just as effective. Against seemingly insuperable odds, it was more than good enough. Plain soap was leverage.
The secret, he pointed out to me, was that the soap was more than soap. It was a behavior-change delivery vehicle. The researchers hadn’t just handed out Safeguard, after all. They also gave out instructions—on leaflets and in person—explaining the six situations