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By Jarrod Goentzel

Fear of an Ebola outbreak in the United States has spurred two key proposals for preventing the spread of this deadly disease: travel bans from West Africa and stockpiling Personal Protective Equipment (PPE).

These measures have merit, but they could also severely disrupt the supply chains that deliver the workers and supplies that are critical to fighting the Ebola virus.

PPE stockpile in Ohio (Photo: Ohio Department of Health)

Stockpile of personal protective equipment in Ohio (Photo: Ohio Department of Health)

Travel Bans

Many public officials are calling for travel bans from countries most affected by the disease: Guinea, Sierra Leone and Liberia. Some countries and individual airlines have already implemented such measures.

Flight restrictions are fairly easy to implement, but have broad implications. Mid-August cancellations implemented in Senegal provide a good illustration. Brussels Air – one of two airlines continuing flights into Liberia – had to suddenly halt flights because it was using the airport in Dakar, Senegal, as a stopover en route to Monrovia. Brussels Air was able to rework its timetable and resume flights after several days. This temporary outage not only delayed arrival for aid workers booked on these flights but also critical cargo of medical supplies, including supplies sent by our lab.

Advocates of bans argue that special charters can replace commercial air for humanitarian purposes. But the decision in Senegal also halted service provided by the U.H. Humanitarian Air Service (UNHAS) on August 22 until a special facility could be built; flights resumed again on September 25, over one month later. To stay ahead of an outbreak, alternate transportation capacity for aid workers and supplies must be fully in place prior to implementation of any travel bans.

Establishing new air transportation networks takes time and significant funding. As of October 5, the UN had transported a total of 655 passengers with its air service and had recently added a 737 between Ghana and Liberia twice a week. Privately funded air bridges, such as Airlink for cargo from the U.S., are providing additional capacity. Finally, it takes time for humanitarian organizations to piece together a supply chain spanning new networks of donated services.

The public health debate regarding the effectiveness of travel bans will no doubt continue. In making decisions, politicians must also consider the supply chain impact of eliminating commercial air capacity that has been shaped by market forces and made reliable by years of execution.

PPE Stockpiling

Recent Ebola cases in the U.S. have heighted awareness of the Personal Protective Equipment (PPE) that is critical for health workers. Fueled by health sector preparedness as well as rising personal panic (sales on Amazon are soaring), manufacturing capacity for PPE may be become constrained. Already, the State of Ohio is buffering its stockpile, and some distributors are citing supply concerns.

Capacity constraints or bottlenecks combined with volatile demand, such as that faced during an outbreak, escalate the importance of coordinated planning and prioritization. Fortunately, two international organizations took the early lead in matching PPE supply and demand. Médecins Sans Frontières (MSF) has led Ebola treatment on the ground in West Africa from the beginning, determining the standards for care and health worker safety and quantifying needs. In early September, UNICEF raised the issue of manufacturing capacity for PPE and began coordinating with key suppliers. Together with the WHO, MSF and UNICEF have sent clear requirements to manufacturers, which have responded. DuPont added shifts and has more than tripled production since March.

However, a few more high-profile cases could rapidly escalate stockpiling efforts in the public and private sector and across geographies. With manufacturing already running at peak capacity, supplies may begin to fall short. Similar situations have been considered before, such as with H5N1 in 2005, where coordinated planning is critical in allocating limited inventories.

Supply chain research indicates that risk pooling – where vital global inventories are co-managed as a common resource – is critical in maximizing the impact of a scarce commodity. As an alternative to stockpiling locally, decision makers in the public and private sector should consider a pooled procurement process, led by the WHO consulting with health departments in affected countries (which includes CDC as the U.S. is affected), that allocates stocks to health workers most at risk.

Adapting public health strategies during an outbreak is critical in preventing the spread of deadly disease. However, hastily considered strategies to control movement and hoard supplies could dramatically impact the availability of our most critical resources – health workers and protective equipment – to fight the disease at its core.

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By Lauren Seelbach

During my summer internship at the American Red Cross (ARC), I explored how social media can be used in the disaster context. Examples could range from identifying pockets of need to fostering communication with affected individuals.

PPE stockpile in Ohio (Photo: Ohio Department of Health)

President Obama touring the Red Cross Digital Command Center (10/30/2012) Photo: http://en.community.dell.com

My project focused on how decision-makers at the ARC are using social media. I interviewed thirty-eight individuals in disaster operations to understand (1) how they were currently using social media in disaster operations, (2) what specific decisions had been informed using social media, and (3) what functionality they felt was lacking in making the link between social posts and decisions.

Based on the analysis of these results, several key recommendations were made on how to apply social media data to operational decision-making. They are to:

  • Define and incorporate a process for using social media in decision-making in existing policies or develop new policies for this process, considering that:
    • The process should be defined for an operational role;
    • The process should be focused on identifying information on which an operational decision can be made;
    • The opportunity to work with any provider of a social monitoring service (e.g. Radian6, Dataminr, HootSuite) should include a process to further refine the software to address the unique needs of a decision-maker;
  • Develop or refine keyword groups in social monitoring software (if using) to pull posts focused on needs and client feedback;
  • Develop an operationally focused training module for social monitoring software platforms and encourage wide participation among staff in headquarters and regional locations;
  • If the organization is reporting social data, incorporate data that is regionally focused, as opposed to or in addition to the “big picture” reporting.

These findings represent actions that any organization can take to increasingly apply social media in operational decision-making, no matter the context. They are relatively simple policies and procedures that solidify the place of social media as a relevant information source in decision-making.

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By Jarrod Goentzel

(Photo: European Commission DG ECHO/Flickr/Creative Commons)

Nine pallets of caps, gowns, boots, and masks are sitting at the JFK airport in New York City awaiting the next available flight to West Africa. This might appear to be a routine shipment delay, but it is not. The supplies are needed by doctors in the fight against the deadly Ebola virus, and the holdup highlights a worrying gap in the humanitarian supply chain.

The personal protective equipment (PPE) – shipped by our team of doctors and logisticians in Boston[1] – is destined for the Ministry of Health and Social Welfare in Liberia, which will then distribute supplies to locations at the front lines of the health crisis such as JFK Memorial Hospital in Monrovia. PPE is essential in the fight against the Ebola virus, protecting the brave doctors and nurses who continue to diagnose and treat patients every day at their own peril.

Our “freight forwarder” collected the pallets on August 18 for consolidated air freight service, which normally means airport-to-airport delivery within three to five days using space available on commercial (passenger) airlines or dedicated cargo flights to the destination. By consolidating cargo from various shippers, freight forwarders reduce the cost of air shipment significantly from express services, which is important when shipping multiple pallets.

And here is the rub. In spite of repeated statements from the World Health Organization (WHO) advising against travel bans to and from affected countries, commercial airlines have suspended service. Clearly this constrains the ability for the international humanitarian community to send aid workers. But due to the role passenger flights play in providing air cargo capacity, these travel restrictions are effectively quarantining critical medical supplies outside Ebola-affected regions.

As of August 25, with our pallets still sitting at JFK airport, there are only two options remaining for commercial air service to Liberia: Royal Air Maroc (with service three times per week from Casablanca) and Delta (which is halting service August 31). Most of the flights to Liberia, and their air cargo capacity, were suspended:

  • Arik Air: Banned flights to Liberia and Sierra Leone beginning July 28. Flights to Guinea are continuing, with passengers screened for symptoms.
  • Asky Airlines: Stopped flights to Liberia and Sierra Leone on July 29.
  • British Air: All routes suspended to Sierra Leone and Liberia on August 5.
  • Gambia Bird: Suspended routes to Sierra Leone and Liberia on August 15.
  • Kenya Airways: Suspended commercial flights to Guinea, Liberia, and Sierra Leone on August 19.
  • Brussels Airlines: Cancelled flights to Guinea, Sierra Leone and Liberia beginning August 23.

Humanitarian aid organizations, familiar with responding to disasters where normal air service is disrupted, are chartering flights to cover the gap in air service. However, even humanitarian flights are subject to travel bans, as Senegal recently demonstrated by canceling UN Humanitarian Air Service flights to Ebola-affected countries.

Flying cargo in the space unused by passenger luggage (especially as baggage fees encourage a shift to carry-ons) has long been an efficient option for time-sensitive freight. Travel bans, which at face value seem to prevent the spread of disease, actually constrain the crucial human and material resources required to manage the Ebola outbreak.

Fortunately while writing this blog entry, news broke that Brussels Airlines is resuming flights to Liberia. Let’s hope this is a trend, reconnecting health workers in West Africa with global stocks of critical supplies. Maybe soon our nine pallets will be moving rapidly from airside at JFK airport to patient-side at JFK hospital.

 

[1] Pallets of critical medical supplies were assembled and shipped by a team from Boston Children’s Hospital (BCH), the University of Massachusetts Medical School (UUMS), and Massachusetts Institute of Technology (MIT). Doctors at BCH and UMMS have been working in Liberia for over seven years developing training programs for physicians and nurses. During this crisis, these doctors are supporting their Liberian colleagues by gathering in-kind donations from medical suppliers and transporting them using crowdsourced funds with logistical support from the MIT Humanitarian Response Lab.

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By Thomas Henry Marcil

All industrial sectors of the economy—from insurance to wireless telecommunications—operate in a state somewhere between full competition and monopoly. The same applies to the non-profit services sector, including charities involved in humanitarian and international relief operations. Though it can be uncomfortable to imagine non-profit organizations, built around the kindness of individuals and governments, fighting for revenue and market share, this spirited battle is very much the case in the humanitarian sector.

Since it is difficult to directly measure competition in an industrial sector, economists and policy analysts (carefully) use concentration as a rough corollary. High and low sectoral concentration, depending on the nature of the industry, can offer either benefits or drawbacks to consumers. Industries that are highly concentrated—for example, automobile and cigarette manufacturers—can pass on savings to consumers given superior economies of scale and network effects, yet may also encourage needlessly high barriers to entry for other firms wishing to enter the market. On the other end of the spectrum, highly unconcentrated industries—like the residential and commercial construction sector—can benefit consumers by incentivizing superior quality at the expense of providing consumers an excessive quantity of choices.

Curious to understand more about humanitarian efforts, I wrote a paper for a class last fall identifying macro trends of non-profit international relief firms, including the concentration of this sector and implications for humanitarian aid delivery. All charities that file for tax exemption in the United States – including those who identify as international relief and humanitarian organizations – must file an IRS form 990, providing a useful source of information regarding this market. I used these data for my paper.

The chart included here plots the total revenue accrued by this sector and its Herfindahl-Hirschman Index (HHI) – a commonly used measure of industrial

Total revenue accrued and HHI Index over time for the international relief sector

Total revenue accrued and HHI Index over time for the international relief sector

concentration – as a function of time. Since 1989, when the Berlin Wall fell, there have been three major developmental stages in this sector in regards to the quantity of revenue humanitarian organizations acquire from donors, and where this revenue is being allocated.

  • From 1989 to 1998, humanitarian organizations went through a stage of capacity expansion, corresponding to the end of the Cold War, which saw a rapid increase in the number of humanitarian organizations. The HHI decreases during this period, reflecting the increasingly fragmented market.
  • From 1998 into 2008, the market saw a period of volumetric revenue expansion, where humanitarian organizations experienced a five-fold surge in funding. The corresponding rise HHI indicates this surge in funding was increasingly concentrated among the larger organizations.
  • Finally, from 2008 to today the market has experienced a period of volumetric revenue contraction, a result of the financial crisis of 2007 and 2008, and more competition.

Not being a seasoned expert in the sector, I was not sure how to interpret these results. I present them here as an observation about the relationship between the amount and the concentration of humanitarian funding. Further study to understand the state of competition in the international relief sector could help improve governmental policy, organizational strategy, and ultimately the quality of aid delivered to beneficiaries.

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By Dr. Jarrod Goentzel

Companies continually tinker with incentive programs for their employees to align individual behavior with business goals. Visiting a relatively new venture in Zimbabwe, I found a unique incentive scheme to drive efficiency…literally.

A Pulse employee prepares his new truck

A Pulse employee prepares his new truck

Pulse Pharmaceuticals began distributing medicine in the capital city of Harare in 2009. It started small, with only one product line and ambition. By the time I visited in January 2013, the company had grown to around 40 employees and $20 million in sales. As the company grew, some employees had earned a particularly generous company perk – a company vehicle. Note that I did not say company car, because all company vehicles are pickup trucks.

Why no cars? Because this employee incentive scheme aligns with the company’s distribution system. Orders in by noon are delivered the same day, and many pharmacies are open until 8pm. Pulse employees live in various areas of the city. They can make deliveries, which are primarily small pharmaceutical products, on their commute home. Even the CFO is engaged in logistics on a regular basis.

Besides the obvious logistical advantages, this incentive scheme works on several levels. While receiving a company

Cars await distribution to Pulse employees in Zimbabwe

Cars await distribution to Pulse employees in Zimbabwe

vehicle is a notable acknowledgement of an employee’s past contributions, it is also encourages loyalty for key employees to the company. The perk also fits with my observations about the corporate culture at Pulse, which is very entrepreneurial and focused on growth; Pulse rewards individuals with assets that enable them to continue investing their time, particularly their commute, in growing profits. Finally, the perk is not insignificant; tangible assets are highly valued in a country where recent experience with hyperinflation diminished confidence in monetary incentives.

I’m not sure this is the start of a trend. Walmart does not give its top performers a Peterbilt with sleeper cab. Even UPS, where managers often help out temporarily by delivering packages during peak seasons, is not sending its execs home with a brown truck for their personal use. But for a hungry startup in Zimbabwe, this creative incentive scheme aligns personal, cultural, AND logistical goals in a unique way to really deliver the goods.

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By Hisham Bedri

I recently attended the USAID Higher Education Solutions Network (HESN) launch event in Washington DC as part of the MIT delegation. As a belt-way outsider, I always thought USAID and government agencies were distant ivory towers–untouchable by peasants like myself, however this event changed my perspective on USAID. During the event, professors and students from the HESN universities (composed of MIT, UC Berkeley, Duke, Michigan State, William and Mary, Makerere, and Texas A&M) had the chance to meet the leadership of USAID and learn about their renewed commitment to harness the power of science and technology for international development. What was it like to be in the National Academy of Sciences building and the National Press Club next to the top USAID officials and administrators? Remember Willy Wonka and the Chocolate factory? Yeah, It was like that.

Senior Advisor to President Obama on Science and Technology John Holdren and USAID Administrator Rajiv Shaw at USAID HESN Kickoff Event

Senior Advisor to President Obama on Science and Technology John Holdren and USAID Administrator Rajiv Shaw at USAID HESN Kickoff Event

Just as Charlie walked through a factory filled with magic and whimsy, I was walking through one of the epicenters of international development in the world. This is where policy is made. These are the people who make the hard decisions. USAID opened its doors allowing us to meet its top officials, and gave us knowledge of its inner structure and capabilities.

The best take-away from the trip was meeting university professors, students, USAID officials, and other honored guests, all of whom were passionate about international development and science. I was surprised to see so many development labs and such a strong commitment to appropriate technology. There is a growing interest among engineers and scientists to focus their efforts on developing regions and emerging markets.

During our time together – shuttling between offices, eating meals, and participating in a science fair – there were plenty of opportunities to “geek out” and discuss research in depth with peers. I particularly enjoyed discussing geo-spatial analysis with researchers at the College of William and Mary and food security and conflict with researchers at Texas A&M. In addition to informal socializing, I was very interested in the work presented during the science fair. While a lot of impressive research was shown, I think first prize goes to UC Berkeley’s iPhone based microscope for its simplicity and potential impact on remote medical diagnosis.

There was also debate, particularly about how to approach global challenges within engineering education. There is a need for more engineers with skills, passion and the ability to work across conventional fields. Some argued that it is time for a new field: “development engineering and sciences,” while others believe in changing our traditional engineering and science curricula to incorporate the concepts of sustainability and development early. No matter the solution favored by individuals, it was evident to everyone that change was coming.

Difficult questions were posed and facilitated in round tables by Washington’s young leadership. I had the opportunity to meet Presidential Management Fellows (PMF), Presidential Innovation Fellows (PIF), and American Association for the Advancement of Science (AAAS) fellows. These young people are rising stars within the government and are a driving force for HESN – providing organizational backbone as points of contact for universities and finding ways to connect research with USAID needs.  Meeting this group of young people contrasted with my prior vision of government as a clunky, uninspiring machine. This is not your grand-dad’s government; seeing the inner-workings of USAID made me believe that change is possible and that there is serious hope for the future.

MIT crew at HESN kickoff event in front of National Academy of Sciences building

MIT crew at HESN kickoff event in front of National Academy of Sciences building

USAID’s new commitment to science is an important change to the world of international development. International aid and development has become a dynamic field with huge changes in philosophy since the 1960’s. What was once an avenue to give assistance and show compassion (through in-kind donations and investment) has become a specific mission to make lasting and serious change. Officials at the agency were very excited about the use of mobile technologies, geo-spatial analysis, and statistical evaluation for the sake of development goals like healthcare and food security. Furthermore, USAID is playing an active role in crowdsourcing solutions to development problems. The office of Innovation and Development Alliances (IDEA) has organized hackathons and open-data challenges to address development issues. This is exciting because USAID is embracing new opinions and hearing new voices.

I’m impressed by this new commitment because we are taking an appropriate approach to science and technology. Technology by itself is not the silver bullet that will save the world. Often there is a great deal of excitement surrounding newly designed products that turn out to be ineffective in the field. Unless a product is designed with culture, supply chains, and sustainability in mind, products deployed in the field will probably fail. Rarely do we hear when a development product or project fails or learn from our mistakes. The silent failure of products holds back the revolutionary power of technology in international development. USAID is acutely aware of this effect and is combatting it in its new commitment by including programs (such as CITE) to evaluate technologies across multiple platforms, including technical feasibility and supply-chain robustness, and produce easily accessible reports to inform designers about results.

USAID plays an important role in international development and international relations for the US. This new commitment to science and research partnership is very exciting. If humanity can engineer a way to the moon, ending poverty should also be achievable. This partnership is a giant leap in the right direction.

Hillary Clinton on HESN: http://www.youtube.com/watch?feature=player_embedded&v=hhXGKeGoX_s

Where does MIT play a part in this?

MIT was awarded the USAID partnership for its IDIN and CITE programs. The brilliant minds at D-Lab, Department of Urban Studies and Planning, and the Humanitarian Response Lab have drafted these two programs to fill a gap in innovating for interanational development. The first part of MIT’s propsal is IDIN, a global network of innovators sharing ideas and best-practices. The second part of MIT’s proposal is CITE (Comprehensive Initiative on Technology Evaluation). These two initiatives are critical for USAID’s technology transfer and innovation efforts.

 

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By Dr. Jarrod Goentzel

Six months after the earthquake that devastated Haiti and galvanized the international community, lessons are emerging about striking the right balance between faster and better crisis responses, and how both objectives can be met.

Last fall we began a project with Partners In Health (PIH), a Boston based NGO, to identify how the organization’s healthcare supply chain in Haiti can be scaled up. PIH is known for focusing on better, demonstrating that “allegedly untreatable” diseases can in fact be treated in impoverished settings. It is also focused on the long term by involving the community and working with the public sector to strengthen systems. While PIH had extensive experience in Haiti, having provided health care in the Central Plateau north of Port au Prince since the mid-1980s, the earthquake challenged PIH on two fronts: it was not a disaster relief organization and it had no previous operations in Port au Prince. This organization needed to become faster to meet the needs of injured Haitians by establishing mobile clinics in a city where it had no existing capacity.

Previous PIH experience did prove useful in establishing emergency health services.  According to Kathryn Kempton, Director of Procurement for PIH, “We were able to act faster because we had already tackled some parts of the ‘better’ by having a solid formulary, well trained local staff, experience with mobile clinics, and some logistics procedures in place, all in the Plateau.” Still, it was difficult to be both faster and better in setting up the supply chain to support new mobile clinics in the informal settlement camps.

The Cement Warehouse

The day we visited the new PIH warehouse in Port au Prince – an old cement warehouse converted overnight into a medical facility – it was uncomfortably warm and far too humid for effectively storing pharmaceutical products. The majority of the warehouse was well organized, with medical supplies in one room, pharmaceutical products in another, a small dispensary in the corner to effectively serve the mobile clinics, and an electronic pharmacy management system tracking the stocks. However, we did notice some expired medicines stacked against a wall next to a room of surgical equipment that no one had the skills to understand, and hundreds of water bottles piled haphazardly just outside the door.

Faster clearly ruled the choice of warehousing. It simply wasn’t an option to wait until climate-controlled and better-secured warehouse space could be found in the capital city; supplies were flooding in from around the world and they were urgently needed to treat those injured in the earthquake. The supplies reflected what was available rather than what was needed, such as equipment that was too specialized for emergency needs. PIH tried to screen every item before shipment to Haiti, but the sheer volume of donations and the need to respond quickly made this very difficult. Shifting priorities made the task even tougher. Ultimately, the faster solution was to accept everything (necessitating a large warehouse) and sort out what was useful as demand materialized. In the circumstances, opting for faster rather than better was a good tradeoff, since most of the products will be used fast enough that the shorter shelf life does not matter for current purposes. And, as the managers told us, this warehouse – with its ad-hoc inventory – is not a long-term solution: it was the best they could do on short notice.

Looking Forward

The central question now for PIH is how to transition earthquake response resources into a better long-term system for healthcare in Haiti. Though successful in meeting urgent needs, the emergency effort departed from their typical approach in scaling up operations. Kempton reflected, “Had we had tools or just some guidelines/parameters for how to set up rapid response systems that can evolve into longer-term solutions, it would have been an enormous help.”

At MIT, we are focused on developing such guidelines and tools using insights from both commercial and humanitarian supply chain methods. In a classic application of commercial supply chain methods, students modeled the PIH supply chain to show how they could scale up operations within existing facilities simply by changing ordering policies from annual to monthly or even quarterly. Another research project shows that there are insights to be gained for commercial logistics from humanitarian organizations who are experts in building supply chains quickly for emergency response. Supply chain design techniques like mathematical optimization may provide better solutions but require more data and time than are available in a disaster response. To be faster, humanitarian logisticians use their experience and intuition to make decisions. We observe decision-making during humanitarian logistics training exercises to formally document some of these heuristic approaches. We are developing tools, including a shipment planning tool for the UN World Food Programme, that should improve results by combining models that are better with intuition that is faster.

The tension between “faster” and “better” is likely to recur in the years ahead. It’s worth our while to invest in solutions now, while lessons are fresh, to enable a faster AND better response next time.

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