Up and Riding [6]

Countryside near Segbwema, South East Sierra Leone
Thursday, June 15, 2017—Dispatch 6

By Randy Thomas Jones

In the role-playing during Saturday’s training process I had pretended to refuse to allow the survey to proceed, but relented with a little more polite convincing by the surveyors-in-training, but I had one more trick up my sleeve, and at a random point during the survey I launched into a completely unrelated and fabricated story about some recent goings on in my pretend village, not allowing them to get a word in edge-wise. In fact, both of these situations, or ones very similar to it, were encountered within our first few days of work in the field. General discussion ensued, and all the new surveyors had been given their first notice that completing the task successfully would require some thinking at each new village.

Randy chats with villagers. [Photo Credit: Ivan Gayton]
Sunday was a “day off,” which for Ivan and me meant a full day of attempting to catch up, he mostly concentrating on giving us a reliable path for data transfer, considering that electricity and data signal both seemed in short supply. The mobile Server (that small device I mentioned earlier called an “Edison”) had also broken down, very uncharacteristically. And of course, it was only on this occasion, when we actually needed a back up, that all of the extra Edisons Ivan usually brings, were left back in North America. A solution is jury-rigged, and we will proceed on schedule for Monday morning with day two of training, a day in the field, and actually attempt to gather data, though our goal here would be training, not high production. In any event, we are interested in establishing quality first. Even with the best attempts at gathering this kind of data, it is a standard procedure to “clean the data” before sharing as a courtesy to other users, and for practical usefulness. But the original gathering must still be done with care and attention.

In short order, we make a brisk departure, which is to say we eventually depart together about 10h00, after most of the surveyors, motorcycle riders, and the usual hangers-on have been present at our guest house since about 07h00. The guesthouse is typical of many African compounds. The household is run by “Grandma,” who is the head of a variously large family that seems to include about ten children under 5 and an assortment of other relatives and friends that swells to about 20 people on an average day. The kids faithfully come down to the water pump (the famous seemingly bomb-proof India Mark II) to get water, which they carry up the hill to the big house. This task is impossible to accomplish without smiling at us and waving hello, grinning and laughing if we pretend to play hide and seek with them, or dance alongside their movements as they pump water. I never knew that it was a requirement to dance as you operate the water pump, but it makes a lot of sense.

Convoy. Photo Credit Rupert Allan
Convoy of bikes during training. [Photo Credit: Rupert Allan]
Each village has its own unique character; they have varying sizes, and of course any particular village is in the mood of the moment when we arrive in our convoy. The concept of a convoy has to be explained to the drivers; and one of the motorcycle teams is lost for a couple of hours until we meet up again. It is mostly easy to find the chief—it is not a big deal, just par for the course. Sometimes we end up at the chief’s house, and visit on the front veranda. The surveyor is often invited to sit, everyone who is able to grabs a bit of any available shade, and of course Ivan and I are offered the best chairs. I try to stand until I am specifically invited in, but only get away 60% of the time with my insistence that the chief retain the best chair for himself.

We don’t want to appear the overlords, but in practical fact, we are to some degree. We are arriving from high income places with what is a small boon to the local economy, the money that we are spending locally for food, lodging, supplies, and wages for the surveyors and riders. Especially since the Sierra Leone Leone (the unit of currency) has plummeted in value. Our guesthouse, for example, has only cost 50,000 SLL per night, the princely sum of 7USD. We get our favored “Bread and Egg” in the morning for 1USD (7500 is the current exchange) composed of the excellent local bread (shaped like a French loaf, though our morning sandwich is only about 25cm), 2 fried eggs, and mayonnaise. It is cooked locally in the market on a small burner stove; it is a typical thing to see in West Africa. Ansu seemed to frown at us the first time or two, but becomes friendlier once he realizes we will be loyal customers, and really don’t mind waiting—as long as he doesn’t make us wait longer than the locals!

At the village interviews, Ivan and I try to hang back; Stanley and Alberta, who have the more dynamic leadership personalities, and also experience, don’t need practice filling out surveys; they watch like mother hens as the trainees take turns running through the surveys, mostly successfully. Ivan clucks over his GPS points and spelling of names, my bent of expertise goes toward the stylistic, and together, along with the generous talents of Stanley and Alberta, a village is completed, and the convoy moves forward. Ivan, however, ever the technically-minded and knowledgeable manager, will get progressively more anxious, especially as the day proceeds successfully: according to him, the data is not really gathered until it is safely downloaded into his Server, and then protected by a secondary copy to a cloud location. Data quality and protection is a matter of life and death in the work we are doing.

If you could ask just one question [5]

Segbwema, South East Sierra Leone
Wednesday, June 14, 2017—Dispatch 5

By Randy Thomas Jones

It is typical of this kind of fieldwork that keeping a daily log of activities is a challenge. I’m actually writing this a week delayed, attempting to capture the mood, but to also share all-important introduction for those who are not initiated into the complexities of the world of humanitarian work and conflict response. I am one of those people myself, though I’m forced to play a fast pick-up game to get up to speed as quickly as possible; the demands of working on a project like this force everyone involved to become multi-faceted and interdisciplinary.

Ivan Gayton, the project originator and CEO, is able to move seamlessly through the varying demands on his attention and knowledge. He’s got internal radar for so many of the things that to me, as an outsider, would demand attention, discussion, and thoughtfulness. It is not that he doesn’t give thought to the various issues that arise, it is just the fact that his experience is so broad, it often looks to an outsider that he doesn’t even have to consider what to do in any given situation. Add to that a native drive for action, and by Saturday morning, less than 48 hours after we have arrived, a crew is assembled at our guesthouse for training on the surveying process.

We manage to get an independent off-line local server operational, at least temporarily. It is a small gadget (called an “Intel Edison”) that easily fits in the palm of a hand, which functions as a repository of the ODK (Open Data Kit) software that we use. Ivan is able to ignore the chaos that surrounds the scene much better than I. News of our presence has already travelled, and even though we are only offering about 4 or 5 positions for surveyors, attempting to state clearly that anyone who wants to apply must have an Android phone which will successfully take a GPS point, there are at least another ten people milling around who it seems do not have phones, or at least do not turn up in our verification process.

The first step to filling out an Open Data Kit Android phone survey

Anyone who has a phone is instructed to download the app ‘ODK’ from our Server, and then fill out our “Surveyor Registration” survey. Open Data Kit: for data collection of all sorts worldwide. It is a wildcat procedure—part of the test is whether a potential candidate can focus on the instructions and complete them. It is not completely Darwinian; Ivan is more than happy to help if someone gets in the queue and asks for help. (In fact, that is one hallmark of a likely good candidate, we are happy to contribute time to training, but there is a limit to the amount of energy that can be devoted to it). The experienced surveyors help also to get the phones loaded up with ODK and the registration survey.

Ultimately, the surveyors will go out with a similar form to fill out on their phones, one that has been designed by us using the background development tool, XLSForm, and that is how we will gather information about the all-critical proper village names and locations. Since the GPS is critical, the surveyor registration form includes the task of gathering a GPS point. Not all of the phones are able to complete the task properly, and discussion ensues about the possibility of showing up with a working phone and continuing. Yes, some allowance for this will be made, but it had better happen fast, we are planning to get on the road on Monday for our first field test.

Through the Open Data Kit survey software, and its associated support, what shows up on a mobile device (Android based only) is a simple form than can handle much more complexity than we need for this project. For our purposes, we are only attempting to disambiguate place names for the purpose of healthcare. In fact, Ivan will repeat himself several times over the following week in various meetings: “We are a public health project using mapping, not a mapping project. I love maps, but what I care about is saving lives.” The ODK software has been around a while (and there are also other versions with slightly differing specifications since it is an Android software), and it seems whenever anyone is doing a project, everyone has a curious desire to get an extra question added to the survey.

Ivan resists as best he can all comers. His general answer is a polite reminder that the phone number of the village chief is one of the critical pieces of data that we are gathering. When the data is uploaded, humanitarian agencies will literally have the ability to give a phone call to any of those villages, which, much more often than not, will have a skilled English speaker available. He has to bow good-naturedly, of course, to the Red Cross request to add a question about the presence of village markets. MSF likewise gets a question added about the availability of working water pumps. In my enthusiasm, after the first field day and we accidentally discover a story about the meaning of the name of the village, I argue to include that as a question as well. Our colleague Rupert Allen, who will be joining us shortly, has an academic interest in the way people are dealing with new technology. He would like to add a few questions as well, Ivan gives him one, he is not, as it turns out after all, a complete ogre!

Back at the training day, there are enough people who have sent a form with a correct GPS point to the Server (which can immediately be verified y reviewing the database as it emerges) to begin training. It is not a completely logical step-by-step process, but once the basics are introduced, everyone gets a copy of the real survey and we begin practice. Just as the survey design is critical, or perhaps why the survey design is critical, the asking of questions can’t be a completely rote process—some attention is given to explaining the intention behind the questions and the idea that people’s point of origin coming to a health facility will be a good thing.

Our general instruction is to ask for a knowledgeable villager (often the village chief). This is not as pompous as it might sound, it is simply a paying respect similar to the idea that you probably wouldn’t immediately walk into someone’s back yard in a Western context, you would knock at the front door and introduce yourself first—the chief is the front door of the village. This provides an opportunity to do some role-playing, with one of the experienced surveyors playing the role of the chief, and the other two coaching on the side.

After about three or four rounds, it is starting to go fairly well, and I offer to step in as temporary chief, planning secretly to mix it up and cause a little trouble to test the resilience. I know Stanley, Alberta and Richard can handle it.

The first task is saying hello and explaining briefly that we are trying to make the map accurate because it is kind of insulting that the villages are not even known to exist in the outside world. It is mostly going to be an easy sell, but during the Ebola outbreak a few places had to be forcibly quarantined, we have to account for the possibility of refusal, and indeed, consent to the process is a gold standard. My first response in the role-playing is to proclaim that I don’t want my village mapped, and to tell the surveyor prospect to leave the village! This causes a little laughter, but there is also a good kind of confidence, “Can I just explain what we are doing?” says the surveyor-in-training. “Yes, that is acceptable,” I reply. With a bit more chance to explain, the chief gets convinced, the survey can proceed, but I am not out of ideas to stir up a little trouble yet.

Like Information, Maps want to be Free [4]

Segbwema, Kailahun District, Sierra Leone
Tuesday, June 13, 2017—Dispatch 4

By Randy Thomas Jones

Friday afternoon, after our visit to the Nixon Memorial hospital, we hit the ground running again, getting some possible candidates for the positions of surveyors and drivers. The surveyors have to have a working Android phone that can take a GPS point. We get them to download the Open Data Kit app (ODK for short) and install it. Then they have to find a simple survey: “Surveyor’s Registration.” Name, address, phone number, GPS point. If they can do that, they are still in the field. Five of them are successful, though the group is salted with a couple of ringers.

Alberta and Stanley were both involved in mapping projects that happened following the Ebola outbreak in 2014. They know the ropes, and it is important to get them assisting with training and informal leadership. That provides a level of redundancy, the opportunity to refine instructions in the nuances of the local language, and provides aspirational models for the other new candidates. With us also, from Freetown, has been Richard Bockarie, a Sierra Leonean with a variety of relevant skills. He’s done mapping before as well, and even knows how to do some of the programming behind the scenes; he can be an asset to the project.

Along the way, I’ve again had the pleasure of learning from Ivan some of the history of computer programming. It isn’t directly relevant to the daily tasks of painstakingly asking for a receipt for every purchase, the obligatory defeat of dehydration that forces a stop to pick up bottled water, the endless need for a catlike agility to deal with simple unexpected circumstances, but it is good to know a little bit about the subject because it is an important thing philosophically for the project and our partners.

The argument is structured around perceptions of the value of information, technology, and programming. Early on, most people in computing thought that programming would be a part of computers that no one would pay for, and that the value was in the hardware. Later, it became apparent that the programming had economic value after all. But one of the early designers of computing wanted to buck the trend that was developing toward proprietary programming.

‘Free,’ yet ‘priceless’ maps, can save lives.

getting some shade
Arrival in a village, shade is both sought after and freely offered.

There was one strong ethic in the early computing development of free-wheeling creativity—if you want it, go ahead, make it up for yourself . . . and for everyone else as well. If someone adds to what you have done, fantastic, you will probably borrow something that they have made next week. It is a share and share-alike community. Along the way, the phrase “information wants to be free” emerged as a slogan.  Information wants to be free doesn’t mean free of charge, it means free to move, be utilized, be accessible. Here is where we loop back around to the value of humanitarian mapping. Maps, Ivan would say, also want to be free. They paradoxically get more valuable as time passes when they are available to use as a part of public infrastructure, especially when used as a foundation for the improvement of public health. “Free,” yet “priceless” maps, can save lives.

Returning from one of his MSF missions in 2013, Gayton was ready for a desk job in London, England. (He had also acquired a family by this point). The year was 2014. He walked to work with enthusiasm the first day and settled in looking for the same background base maps that he had seen in Haiti 4 years earlier. But by the end of the first week, he realized that there was no background maps like there had been in Haiti from the intense contribution made by the digital humanitarians of the Humanitarian OpenStreetMap Team and Haitians living in the US. In most other areas, there is no strong expat group of diaspora who had taken up the task. The situation was unacceptable to Gayton, and after a little more cross checking, his suspicions were confirmed—the early seeds of a plan started forming. Let’s return later to that, and jump back to Sierra Leone where we are beginning to implement some of the ideas that started developing that day back in London.

It is only our second day on the ground in Segbwema, a town of perhaps a thousand people, but we must return to Kenema in our first attempt to deal with our technical problems. There is actually no electricity during the day, though the Nixon Hospital is able to light up the town in the evening because they have a field of solar panels. We pay extra for a generator, but somehow the fuel, much to my dismay, it doesn’t actually last until the promised 7:00 am, only until 5, when I happily awake ready for coffee that I can’t make because I have neither coffee nor hot water. During a later sojourn for supplies, I manage to find powdered instant coffee (typical in West Africa), and powdered milk. It is at the electrical equipment store, which is tracked down with the usual quick few referrals, that I come upon a plug in kettle. I also manage to secure my packets of instant Nescafé coffee.

We’re not at the electrical store for the kettle that I covet; we are in a rush to set up an independent power supply so that our high tech equipment will work. Happily, they have a battery Ivan is content with, and an inverter. The inverter is a 12V to 220V Alternating Current unit. When we do have power, we will be able to plug in and recharge the battery, (a 12 V 100 amp hour unit, which is twice the size of a car battery, that proclaims its ability to operate at 25 degrees Celsius). I think we will certainly be able to manage the temperature requirement here in tropical Sierra Leone, and when we don’t have power, in theory, we’ll be able to plug in phones and computers to recharge . . . to some degree, as it is said. They also offer us a solar panel, and it does cross my mind to enquire whether it would provide enough juice for my kettle, but my attention is quickly drawn towards the next step in our adventure.

Where do we send the Ambulance? [3]

Segbwema, Kailahun District, Sierra Leone
Monday June 12, 2017—Dispatch 3

By Randy Thomas Jones

Today I’ll return to the story about how contact tracing, maps and public health all connect the dots that form an arrow pointing us to come here to the verdant and vibrant atmosphere of West Africa, to gather people with Android phones, to find motorcycles with their drivers, and make maps of places that can literally be “off the map.” In many cases, being unrecognized means that voices from the hinterland are not noticed, and this is the first step to helping people say to the administrative systems of the modern world, “We are here.” In a way, an analogy could be that if one called for an ambulance in the modern world, one would expect to be asked, “Where are you?” And given an answer, to expect them to arrive. In low-income settings, sometimes the difference between being known and unknown is a difference between life and death.

With Nigel Jagbwem OSM
Screen shot, indicating example of geotagging photos as part of a data set. [Photo Credit: Rupert Allan]
Yesterday I was discussing the need for mapping in Sierra Leone, and how the lack of accurate maps and gazetteers hampered the response to Ebola in 2014. In Nigeria, on the other hand, extremely aggressive contact tracing did effectively stop the outbreak before it became an epidemic. Nigeria had the infrastructure available to a wealthier state that made it possible to ask the key question of where patients were from and receive an unambiguous answer. Sierra Leone has been declared Ebola-free for 18 months now, but Sierra Leone is still considered “At Risk,” because the virus is in the environment and could again transfer to the human population.

One of the things that becomes apparent after some consideration is that the creation of maps and an unambiguous gazetteer (which lists not only village names, but the association with higher administrative districts) is much better done before a crisis hits. And of course, registrars at clinics and hospitals have to understand why it is necessary to use them, and be insistent on a full answer when asking, “Where are you from,” or, as sometimes is the case when someone brings in a friend or relative, “Where is this person from?”

Dr. Monk is developing his portfolio to focus on both UK-based medical practice and Global Health for Alternative Certification in Core Medical Competence, enabling him to tailor his studies to his interest area of epidemiology, infectious diseases and microbiology. He’s a congenial ball of fire when he invites us to the local bar in Segbwema Thursday night, and he and Ivan happily trade stories, both of them enjoying the meeting of minds with similar obsessions. Ivan considers him a great resource as a friend to the project—the more typical situation is that doctors don’t pay that much attention to public health (again, that old bias of the consequentialists). Doctors, and quite rightly, tend to be Kantians.

Friday morning we walk up the hill from our guesthouse to meet Monk. Or, more precisely, he arrives at 8:00 in the morning with a typical British enthusiasm and a warm invitation to the canteen at the Nixon Memorial. A breakfast that is unusual, for the Western palate, composed of fish and rice, but I do remember the “Egg and Bread” from my visit to Ghana last year, and determine to track that down whenever possible!

motorcycle track
Typical of some percentage of village access trails, impossible to transverse with even a 4 wheel drive vehicle—walk or bike! [Photo Credit: Rupert Allan]
After breakfast, we take an extensive tour with Ed through the hospital find out that the Nixon Memorial Hospital has surprisingly good practices for registration. “Daddy” is the registrar at the outpatient desk, and takes great pride in his system for keeping track of patients. To the inexperienced eye, it looks like a haberdashery of file cards in randomly placed boxes. In fact, Daddy passes every inquiry regarding how individual patients’ records can be traced through his system. He has aspirations, and borrows a computer to practice his Excel at every opportunity from the hospital lab. Similarly, Betty, who manages the intakes on the wards, confidently pulls out scrolls of old records and points to one. “That would be in that one,” she says. Ivan rates them in the top 10% of facilities he has seen in low-income countries (the term he prefers to the usual terms “undeveloped / underdeveloped / developing”).

What started out seeming to be a quirky interest in records turns out to be only the “responsibility of care.” I’m getting enthusiastic about records myself at this point, and there is a certain kind of devotion to the practice that is as important as remembering to feed all of your children, and not leave one hungry.

Leveraging the goodwill that Monk has built, we make some very casual inquiries as to the possibility and interest for adding any columns to the intake books. Currently, the disambiguation of towns with the same name is done informally, depending on Betty and Daddy’s admittedly formidable memories. There are complications to this; one of the master books is a federal record that has a specified format that doesn’t meet standards for current best practice. But the answer is a tentative and provisional, “Yes, possibly.”

London to Haiti to Sierra Leone [2]

Kenema, Kenema District, Sierra Leone
Sunday, June 11, 2017—Dispatch 2

By Randy Thomas Jones

We are at the Internet café in Kenema, a town with a population large enough to sustain a full market(1). We could have used the visit for some purchasing, but the priority today is repairing some of our tech. The single independent server we have (Ivan usually brings about 5 of them to ensure redundancy) is inoperative, so he is currently engaged in the traditional activity of travellers since time immemorial—field hacking. It might be time soon for another order of cold water . . . one time is usually all it takes to clarify the issue for the ex pat of whether one is asking for cold water, or just water! And for another thing, the market is closed, the shipping containers that are one of the typical housing for small shops . . . all the small shanties that provide shade for the smaller suppliers are bare—it is Sunday.

kenema hardware store
Typical “hardware store”—a stall with various useful and peculiar items.

On a successful note, Ivan has just procured a piece of wire. Literally one piece of wire, but with the kind of resources that are available in a smaller African town, it was probably a good bet to give up after one wild goose chase in Segbwema this morning. Let the field hacking commence! To return to the introduction to our adventure, or, to use the more generally accepted term, “mission.”

In Haiti in 2010, after the earthquake, Gayton faced a similar problem to the one John Snow faced in London in 1854—cases of Cholera were beginning to arrive at the MSF hospital in Port-Au-Prince, and everyone knew that a second, potentially even more devastating disaster was developing fast. Gayton knew of Snow’s solution, but the problem was trying to identify the neighborhoods people were from was an impossible task.

To describe why the task was difficult perhaps can go back to what many might know from some rudimentary exposure to anthropology—many cultures have names for themselves that simply mean “The People” in the local language. Left to their own devices, people will name things in a vernacular fashion. Haitians were no different than any other people—they didn’t mind at all having dozens of similarly named streets called “Avenue of the Church, “ or “Market Street.” Of course, they know where they are from, but when they are coming into a medical facility, they may be too ill at that point to communicate the extra important information that can disambiguate the Patient Origin, the technical term used in the medical world. And if a person is coming in sick with Cholera, you know that they have only arrived after infecting several other people, who will either be arriving soon, or not even able to make the journey to look for help.

Cholera is actually possible to treat; mostly the issue is rehydration, while a person’s own immunity has a chance to successfully fight the infection. It is not necessarily any kind of heroic rocket science, but it is a daunting task that quickly becomes unmanageable in an outbreak situation. The stress on resources will quickly break any attempt at a logistical solution that relies on the Kantian idea of giving the all and best to each new patient. The outbreak needs to be stopped at its source, or many will die.

Recognizing the gravity of the situation in Haiti, Gayton had an idea . . . identify danger areas of outbreak properly, using modern technology—could Google possibly help? After a series of phone calls, Google sent Ka-Ping Yee, who had actually been invited to join Google in the very early days as a founder. Within a week he was on the ground. The organization Missing Maps (also one of our project partners) had already made what is called a base map, using the knowledge of Haitian diaspora volunteers looking through satellite imagery to name streets. With the help of British Red Cross and MSF UK, Ping and his partner were able to quickly scrap together code that enabled a visual dashboard to be used by administrators. Now it was possible to open a map of the city that showed the cases of Cholera as red dots—a “Heat Map.” At a glance, just like John Snow’s map, you could see where the highest incidence rates were located, and resources could be concentrated on where they were most needed.

motorbikes village
Surveyors at work doing their interviews, “Riders” (the motorcycle drivers typically engage and assist.

Jump to 2014, and now Gayton has been called to Sierra Leone in the height of the Ebola outbreak. Full quarantine protocols have been instituted for MSF staff . . . no one is even allowed to touch another human being during the time of their posting. It is clear that Ebola is another transmittable disease. At the height of the outbreak, 1.7 people were becoming infected out of every case. It was looking like a global apocalypse in a time frame of months. But again, the mathematics were germane—if the infection rate can be brought down to less than 1.0, the epidemic is stopped. Ebola also exists in the background environmental reservoir. It came originally into the human population through consumption of what is called “bush meat” in Africa—often unauthorized or even illegal hunting of wild animals for food sustenance. On its own, left in the forest, it is not much of a danger to humans, but once in the human world, it can become a specter of incredible danger.

At the height of the outbreak, the MSF Ebola treatment facility in Magburaka, Tonkolili District, in Sierra Leone had 110 patients, and effective contact tracing (That old question from John Snow: “Where are you from?”) could only be done for 20% of the patients. Why? Because many villages had identical, or very similar, names. Many people from different walks of life had to risk exposure to the disease to intervene against the developing catastrophe. Any contact with exposed people had to be ended, and here mapping had a sinister side—some villages with known outbreaks had to be forcibly isolated to delay the spread of the disease. The experience was heartbreaking, and MSF had a rotation of three shifts of personnel—one on the ground, while the second group was in recovery from the trauma, and the third group, which had sufficiently recovered, was on a vacation rest before heading back to the field. And the damnable thing was, that the outbreak could have been stopped cold (on this point, Gayton emphasizes by thunderclapping his hands together with a vigorous and defiant grief).

Had the availability of accurate maps and a gazetteer been available there is no doubt that the situation would have been ameliorated. As it was, 12,000 people died in West Africa, actually a testament to the sophistication of modern intervention strategies. It was a light toll, considering the nature of the jeopardy.

(1) The city of Kenema had a population of 200,354 in the 2015 Sierra Leone census. Wikipedia

Mapping and the Trolley Problem [1]

Segwemba, Kailahun District, Sierra Leone
Saturday June 10, 2017—Dispatch 1

By Randy Thomas Jones

I meet Ivan Gayton at the Schiphol Airport in Amsterdam after six months of communication and planning; we’re boarding our KLM flight to Sierra Leone, West Africa. It is Wednesday, the seventh of June. We have decided to name the project West Africa Motorcycle Mapping 2017. Characteristically, Gayton quickly launches into a typical wide-ranging discussion that is mostly lecture. I’m new to mapping, but I’ve had enough of an introduction and mentoring over the last six months to get my feet wet at least to the degree to roughly follow along. This time he gets into describing the tension between Kantian ethics and Consequentialist ethics (probably better known as Utilitarianism, which is more properly a subset of consequentialism) using the classic problem in philosophy that has been named the “Trolley Problem.”

The scenario of the Trolley Problem presents a dilemma: Do you decide to save one person at any cost, or do you decide, as the character Spock claimed to be the correct answer in the classic Star Trek television series, that, “The good of the many must outweigh the good of the few or the one.” The problem is faced in practical ways by every humanitarian and health mission in various ways daily, and needs to be faced head on, seeing the difficulty in the dilemma, and wrestling it out each time. In some ways, the project we are working on is an attempt to deal with the Trolley Problem—to assist in the development of an essential feature of public health infra-structure that supports both ends of the spectrum—being able to improve the general ability to provide public health for everyone at the same time that health can be improved for individuals.

Gayton is in his usual jovial mode, into the action, on-task, with a confidence of experience that allows for a friendly demeanor; he’s got a rare kind of intellect, comfortable in a wide range of topics and modulation from the esoteric to the practical. I’ve known Gayton for 10 years, though not well, introduced through a mutual friend in Canada, a forester turned ecologist that we both know and trust. Gayton worked with our friend Robin Clark because his background included work in Canadian tree planting camps; the set up is in bush conditions for the government-required replanting of areas that have been logged. As Gayton puts it, “I crab-walked sideways using my logistical skills to get into humanitarian aid work and MSF was kind enough to offer me an opportunity.” MSF is short for Medicínes Sans Frontiers, or, as we know it better in the English-speaking world, Doctors Without Borders. They won the Nobel Peace prize in 1999 for their work, and are partners in our current project, along with the British and American Red Cross. The project is being run under the auspices of the Humanitarian Open StreetMapTeam, we call it HOT for short.

MSF and the Red Cross are not the only partners in the WAMM project. Gayton, of course, has many connections after 13 years of experience for MSF including appointments as Head of Mission in some very difficult situations. He was in Haiti after the earthquake in 2010, and that experience formed some of the initial ideas for the adventure we are now engaged on. One of the problems in disaster situations is the danger of disease outbreak. Of course, calling it a “danger” is slightly euphemistic . . . it is more likely than not to happen because of the impact on sanitation and resources that inevitably follows. In Haiti, one of the main concerns was Cholera. The disease has a background environmental reservoir, (the disease exists, but does not usually come into contact with humans)—but when people do get exposed, when individuals become sick, the risk of more people getting sick from other people goes up 100 fold.

It is important to insert an aside here, particularly regarding the facts of the matter about the Cholera outbreak in Haiti. Though tropical Haiti is an ideal environment for Cholera, historically, it had been Cholera free. Haiti is surrounded by countries that are, relatively speaking, rich. They have historically dealt with any isolated cases quickly and efficiently. In Haiti, Cholera was actually introduced by UN peacekeepers through the dumping of raw sewage into the Artibonite river. Haitians noticed at the time, and complained vociferously, but the Nepalese ignored them. The United Nations is currently wanting to “wash its hands” of the situation, even though there is a pending case in a US Court. The MSF team wasn’t aware of this at the time, all they knew was that people were showing up at Triage with what soon proved to be Cholera.

Triage simply means “sorting.” In the western world, it is used to refer to primary, secondary, and tertiary care. Primary is something like a simple cut that needs a bandage; tertiary is admittance to a hospital. In crisis work medicine it refers to the designations Green, Red, and Black. Green means the patient will survive without immediate care, Red means that immediate treatment is necessary to save life, Black means that the decision will be made to not help; the person is beyond assistance, or, more wrenchingly, that the resources necessary to help them would leave insufficient resources for a larger number of those who can be saved. In a crisis situation the Consequentialist reality means that gut-wrenching decisions have to be made daily. MSF and other crisis response workers say that doctors working in the western world never need to do Triage—everyone is considered to be on the Red list, and resources are imagined to be infinite.

Map made by English Physician John Snow in 1854, showing point of origin for Cholera cases in the outbreak.

The story of how mapping is relevant to all of this is a fascinating one. One good place to begin is back in 1854 in London England, where there was also an outbreak of Cholera. English physician Dr. John Snow, riding the heady enthusiasm of the 19th century’s confidence in science and more sympathetic view to interdisciplinary approaches to problems that had its origin in the renaissance, decided to look at the outbreak mathematically, not primarily as a physician, who always want to be biased toward the individual (Kantian ethics), but to look at it from the perspective of helping the most people possible, (the Consequentialist position) realizing that some energy had to be spent on the source of the problem, otherwise more individual people would continue to become sick, and the supposed benefits of the strict Kantian position would become void. Snow wanted to find out where people lived—what was the possible commonality between them? That led to the creation of a map, and the foundation of modern public health care. It turned out that the map showed clearly a cluster of patient origin . . . and it wasn’t difficult then to realize that one of the water sources they shared, the “Broad Street Pump,” was a possible culprit. Snow locked up the water pump and stopped the Cholera epidemic in its tracks.