It’s not often I read a paragraph, gape, put the book down and say ‘well bloody hell’ and then stare out the window cogitating. The Checklist Manifesto is the guilty party, an excellent read from American surgeon Atul Gawande. Am only half-way through, but it’s of no surprise that Atul a) has a bit of a crush on checklists b) will eventually end the book saying ‘create checklists, they’re awesome.’ However, the unexpected part is where Atul relates stories of where checklists are used and their impacts. The allegories are incredible. My favourite is below
Karachi in southern Pakistan, a city twice as populated as London, isn’t anything out of the ordinary in the Indo-Pak region: corruption, political instability, inadequate health services and vast slums on the outskirts of the city. In the impoverished and crowded barrios, there is inadequate water and sewage systems, illiteracy and lack of jobs. Mortality rates amongst children are incredibly high. Enter stage left Stephen Luby, an American working with the Centres for Disease Control and HOPE International, with a crazy idea of how to improve health standards in the slums: using soap.
In 2005 Stephen published a paper after considerable testing in the slums using normal soap, anti-bacterial soap and a control area where no soap was distributed. During the testing period (it made no difference whether it was ant-bacterial or not, remember that next time you’re at the check-out counter in a store), incidents of diarrhoea amongst children in neighbourhoods dropped by 52%, pneumonia fell by 48% and impetigo (a bacterial skin infection) dropped by 35%. The families in these areas were still drinking the same contaminated water, so was soap really that effective? Yes and No – it’s the way the soap was used.
The soap was a ‘behaviour-change delivery vehicle’ i.e. the researchers hadn’t just handed out three bars of soap a week, but gave instructions—on leaflets and in person—explaining the six situations in which people should use it such as going to the toilet, wiping an infant and preparing food. This was essential. This is all positive and noteworthy, but the jaw dropping bit? Take it away Atul:
When one looks closely at the details of the Karachi study, one finds a striking statistic about the households in both the test and the control neighbourhoods: at the start of the study, the average number of bars of soap households used was not zero. It was two bars per week. In other words, they already had soap.
So, what changed? The CDC and HOPE gave soap out for free, removing he economic constraint of buying soap, meaning people were more likely to use it. Secondly, they made a checklist of when soap should be used, a simple step-by-step process to manage it. Long live the humble checklist!
And so, as I work through my own Sunday checklist of things to do, I wish you the very best from a cobalt blue sky over an autumnal Melbourne, and will leave you with this: read more; make checklists; and remember to wash your hands.
Writing and writing...